Therapeutic Nurse-Client Relationship PDF (Revised 2006) - CNO

PR ACTICE STANDARD Therapeutic Nurse-Client Relationship, Revised 2006 Table of Contents Introduction 3 Components of the nurse-client relationship 3 Glossary 4...

PR ACTICE STANDARD Therapeutic Nurse-Client Relationship, Revised 2006 Table of Contents Introduction 3 Components of the nurse-client relationship 3 Glossary 4 Standard Statements 5 1) Therapeutic communication 5 2) Client-centred care 6 3) Maintaining boundaries 7 Giving and accepting gifts 8 4) Protecting the client from abuse 9 How To Apply this Standard 11 Decision tree 11 Warning signs of crossing a boundary 12 When a colleague’s behaviour crosses a boundary 12 Maintaining a Quality Practice Setting 13 References 14 Suggested Reading 15 Appendix A: Abusive Behaviours 16 Appendix B: Nursing a Family Member or Friend 17 VISION Leading in regulatory excellence MISSION Regulating nursing in the public interest Therapeutic Nurse-Client Relationship, Revised 2006 Pub. No. 41033 ISBN 978-1-77116-112-1 Copyright © College of Nurses of Ontario, 2019. Commercial or for-profit redistribution of this document in part or in whole is prohibited except with the written consent of CNO. This document may be reproduced in part or in whole for personal or educational use without permission, provided that: due diligence is exercised in ensuring the accuracy of the materials reproduced; CNO is identified as the source; and the reproduction is not represented as an official version of the materials reproduced, nor as having been made in affiliation with, or with the endorsement of, CNO. First published March 1999 as Standard for the Therapeutic Nurse-Client Relationship Reprinted January 2000, October 2000, October 2002. Reprinted January 2005 as Therapeutic Nurse-Client Relationship Revised June 2006 as Therapeutic Nurse-Client Relationship, Revised 2006. Reprinted May 2008. Updated June 2009. Updated footnote May 2013 (ISBN 1-897308-06-X). Updated February 2017. Updated May 2018 following amendments to the Protecting Patients Act, 2017 (Bill 87) Updated December 2018 to remove references to retired practice guideline, Culturally Sensitive Care. Updated June 2023 to add Code of Conduct to suggested reading list. Updated April 2019 for references to Child, Youth and Family Services Act, 2017. Additional copies of this document may be obtained by contacting CNO’s Customer Service Centre at 416 928-0900 or toll-free in Canada at 1 800 387-5526. College of Nurses of Ontario 101 Davenport Rd. Toronto, ON M5R 3P1 www.cno.org Ce fascicule existe en français sous le titre : La relation thérapeutique, revisée 2006 no 51033  3 PR ACTICE STANDARD Nursing standards are expectations that contribute and attitudes required to practise safely; to public protection. They inform nurses of their describe what each nurse is accountable for in accountabilities and the public of what to expect of practice; and nurses. Standards apply to all nurses regardless of their provide guidance in the interest of public role, job description or area of practice. protection. — College of Nurses of Ontario Components of the nurse-client Introduction relationship At the core of nursing is the therapeutic nurse-client There are five components to the nurse-client relationship. The nurse1 establishes and maintains relationship: trust, respect, professional intimacy, this key relationship by using nursing knowledge empathy and power. Regardless of the context, and skills, as well as applying caring attitudes and length of interaction and whether a nurse is behaviours. Therapeutic nursing services contribute the primary or secondary care provider, these to the client’s2 health and well-being. The components are always present. relationship is based on trust, respect, empathy and professional intimacy, and requires appropriate use Trust. Trust is critical in the nurse-client of the power inherent in the care provider’s role. relationship because the client is in a vulnerable position.3 Initially, trust in a relationship is fragile, This document replaces the 1999 Therapeutic Nurse- so it’s especially important that a nurse keep Client Relationship practice standard, and provides promises to a client. If trust is breached, it becomes greater clarity and direction on: difficult to re-establish.4 giving gifts to and receiving gifts from clients; accepting power of attorney on behalf of clients; Respect. Respect is the recognition of the inherent setting appropriate boundaries for the dignity, worth and uniqueness of every individual, relationship; regardless of socio-economic status, personal identifying and dealing effectively with attributes and the nature of the health problem.5 unacceptable and/or abusive behaviour in nurse- client relationships; and Professional intimacy. Professional intimacy is exercising professional judgment when inherent in the type of care and services that nurses establishing, maintaining and terminating a provide. It may relate to the physical activities, therapeutic relationship. such as bathing, that nurses perform for, and with, the client that create closeness. Professional The College of Nurses of Ontario’s (CNO’s) intimacy can also involve psychological, spiritual practice standards apply to all nurses, regardless of and social elements that are identified in the plan their role or practice area. CNO publishes practice of care. Access to the client’s personal information, standards to promote safe, effective, ethical care, within the meaning of the Freedom of Information and to: and Protection of Privacy Act, also contributes to outline the generally accepted expectations professional intimacy. of nurses and set out the professional basis of nursing practice; Empathy. Empathy is the expression of provide a guide to the knowledge, skill, judgment understanding, validating and resonating with the 1 In this document, nurse refers to a Registered Practical Nurse (RPN), Registered Nurse (RN) and Nurse Practitioner (NP). 2 Bolded words are defined in the glossary on page 4. 3 (Hupcey, Penrod, Morse & Mitcham, 2001) 4 Based on a 1998 interview with Carla Peppler, NP, and Cheryl Forchuk, RN. 5 (American Nurses Association, 2001; Milton, 2005) College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006 4 PR ACTICE STANDARD meaning that the health care experience holds for significant others.7 The appropriate use of power, the client. In nursing, empathy includes appropriate in a caring manner, enables the nurse to partner emotional distance from the client to ensure with the client to meet the client’s needs. A misuse objectivity and an appropriate professional response.6 of power is considered abuse. Power. The nurse-client relationship is one of Therapeutic Nurse-Client Relationship, Revised 2006 unequal power. Although the nurse may not includes four standard statements with indicators immediately perceive it, the nurse has more power that describe a nurse’s accountabilities in the nurse- than the client. The nurse has more authority and client relationship. Use the decision tree on page influence in the health care system, specialized 11 to determine whether an activity or behaviour is knowledge, access to privileged information, and appropriate within the context of the nurse-client the ability to advocate for the client and the client’s relationship. Glossary be considered a boundary crossing. This section defines terminology as used in this practice Client. A client may be an individual, family, group standard. or community. Refer to Appendix A on page 16 for Abuse. Abuse means the misuse of the power criteria defining who is a client for the purposes of imbalance intrinsic in the nurse-client relationship. sexual abuse. It can also mean the nurse betraying the client’s Client-centred care. In this approach, a client trust, or violating the respect or professional is viewed as a whole person. Client-centred care intimacy inherent in the relationship, when the involves advocacy, empowerment and respect for nurse knew, or ought to have known, the action the client’s autonomy, voice, self-determination and could cause, or could be reasonably expected to participation in decision-making.9 It is not merely cause, physical, emotional or spiritual harm to the about delivering services where the client is located. client. Abuse may be verbal, emotional, physical, sexual, financial or take the form of neglect. The Culture. Culture refers to the shared and learned intent of the nurse does not justify a misuse of values, beliefs, norms and ways of life of an power within the nurse-client relationship. For individual or a group. It influences thinking, behaviours considered abusive and relevant criteria, decisions and actions.10 refer to Appendix A on page 16. Psychotherapeutic relationship. A Boundary. A boundary in the nurse-client psychotherapeutic relationship involves planned relationship is the point at which the relationship and structured psychological, psychosocial and/or changes from professional and therapeutic to interpersonal interventions aimed at influencing a unprofessional and personal. Crossing a boundary behaviour, mood and/or the emotional reactions to means that the care provider is misusing the power different stimuli.11 in the relationship to meet her/his personal needs, Significant other. A significant other may include, rather than the needs of the client, or behaving in but is not limited to, the person who a client identifies an unprofessional manner with the client.8 The as the most important in his/her life. It could be a misuse of power does not have to be intentional to spouse, partner, parent, child, sibling or friend. 6 (Kunyk & Olson, 2001) 7 (Newman, 2005) 8 (Smith, Taylor, Keys & Gornto, 1997) 9 (Registered Nurses’ Association of Ontario, 2002) 10 (Leininger, 1996) 11 (World Health Organization, 2001) College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006  5 PR ACTICE STANDARD Standard Statements There are four standard statements, each with accompanying indicators, which describe a nurse’s accountabilities in the nurse-client relationship. The indicators are not all-inclusive; rather, they’re broad statements that nurses can modify to their particular practice reality. The indicators are not listed in order of importance. 1) Therapeutic communication Nurses use a wide range of effective to appropriately establish, maintain, re-establish communication strategies and interpersonal skills and terminate the nurse-client relationship. Indicators h) considering the client’s preferences when encouraging the client to advocate on his/her own The nurse meets the standard by: behalf, or advocating on the client’s behalf; a) introducing herself/himself to the client by name i) providing information to promote client choice and category12 and discussing with the client the and enable the client to make informed decisions nurse’s and the client’s role in the therapeutic (see CNO’s Consent practice guideline); relationship (for example, explaining the role j) listening to, understanding and respecting the of a primary nurse and the length of time that client’s values, opinions, needs and ethnocultural the nurse will be involved in the client’s care, or beliefs and integrating these elements into the care outlining the role of a research nurse in collecting plan with the client’s help; data); k) recognizing that all behaviour has meaning and b) addressing the client by the name and/or title seeking to understand the cause of a client’s that the client prefers;13 unusual comment, attitude or behaviour (for c) giving the client time, opportunity and ability example, exploring a client’s refusal to eat and to explain himself/herself, and listening to the finding that it’s based in the client’s cultural/ client with the intent to understand and without religious observations); diminishing the client’s feelings or immediately l) listening to the concerns of the family and giving advice;14 significant others and acting on those concerns d) informing the client that information will be when appropriate and consistent with the client’s shared with the health care team and identifying wishes; the general composition of the health care team; m)refraining from self-disclosure unless it meets a e) being aware of her/his verbal and non-verbal specific, identified therapeutic client need, rather communication style and how clients might than the nurse’s need; perceive it; n) reflecting on interactions with a client and the f) modifying communication style, as necessary, health care team, and investing time and effort to to meet the needs of the client (for example, to continually improve communication skills; and accommodate a different language, literacy level, o) discussing, throughout the relationship, ongoing developmental stage or cognitive status); plans for meeting the client’s care needs after the g) helping a client to find the best possible termination of the nurse-client relationship (for care solution by assessing the client’s level of example, discharge planning with the client and/ knowledge, and discussing the client’s beliefs and or referral to community organizations). wishes; 12 For more information, refer to CNO’s Professional Misconduct reference document at www.cno.org/publications. 13 (Bowie, 1996) 14 Based on a 1998 interview with Carla Peppler, NP, and Cheryl Forchuk, RN. College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006 6 PR ACTICE STANDARD 2) Client-centred care Nurses work with the client to ensure that all professional behaviours and actions meet the therapeutic needs of the client. Indicators these attitudes could affect the nurse-client relationship; The nurse meets the standard by: g) reflecting on how stress can affect the nurse- a) actively including the client as a partner in care client relationship, and appropriately managing because the client is the expert on his/her life,15 the cause of the stress so the therapeutic and identifying the client’s goals, wishes and relationship isn’t affected; preferences and making them the basis of the h) demonstrating sensitivity and respect for the care plan; client’s choices, which have grown from the b) gaining an understanding of the client’s abilities, client’s individual values and beliefs, including limitations and needs related to his/her health cultural and/or religious beliefs; condition and the client’s needs for nursing care i) acknowledging difficulty establishing a or services; therapeutic relationship with a client, and c) discussing expectations with the client and the requesting a therapeutic transfer of care when realistic ability to meet those expectations in the the relationship is not evolving therapeutically context of the client’s health and the available (for example, when a nurse is unable to establish resources; a trusting relationship with a client, she/he may d) negotiating with the client both the nurse’s and consult with the manager to request that another the client’s roles, as well as the roles of family nurse provide care); and significant others, in achieving the goals j) committing to being available to the client for identified in the care plan; the duration of care within the employment e) recognizing that the client’s well-being is affected boundaries and role context;16 and by the nurse’s ability to effectively establish and k) engaging the client in evaluating the nursing care maintain a therapeutic relationship; and services that the client is receiving. f) acknowledging biases and feelings that have developed through life experiences, and that 15 (Registered Nurses’ Association of Ontario, 2002, p. 19) 16 (Forchuk et al., 2000; Peplau, 1991) College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006  7 PR ACTICE STANDARD 3) Maintaining boundaries Nurses are responsible for effectively establishing and maintaining the limits or boundaries in the therapeutic nurse-client relationship. Indicators the boundaries and limits of the relationship (for example, when an identified part of a nurse’s role The nurse meets the standard by: includes accompanying a client to a funeral to a) setting and maintaining the appropriate provide care); boundaries within the relationship, and helping h) ensuring that co-existing relationships do not clients understand when their requests are beyond undermine the judgment and objectivity in the limits of the therapeutic relationship; the therapeutic nurse-client relationship18 (for b) developing and following a comprehensive care example, a nurse providing care to a child who is plan with the client and health care team that a close friend of her/his child needs to be aware aims to meet the client’s needs; of the potential effect the dual relationship has c) ensuring that any approach or activity that on nursing care); could be perceived as a boundary crossing is i) abstaining from engaging in financial included in the care plan developed by the health transactions unrelated to the provision of care care team (for example, a health care team in a and services with the client or the client’s family/ mental health setting may determine that having significant other; coffee with a particular client is an appropriate j) consulting with colleagues and/or the manager strategy that all nurses will consistently use when in any situation in which it is unclear whether counselling the client); a behaviour may cross a boundary of the d) recognizing that there may be an increased need therapeutic relationship, especially circumstances for vigilance in maintaining professionalism and that include self-disclosure or giving a gift to or boundaries in certain practice settings17 (for accepting a gift from a client; example, when care is provided in a client’s home, k) ensuring that the nurse-client relationship and a nurse may become involved in the family’s nursing strategies are developed for the purpose private life and needs to recognize when her/his of promoting the health and well-being of the behaviour is crossing the boundaries of the nurse- client and not to meet the needs of the nurse,19 client relationship); especially when considering self-disclosure, giving e) ensuring that she/he does not interfere with the a gift to or accepting a gift from a client; client’s personal relationships; l) documenting client-specific information in the f) abstaining from disclosing personal information, client’s record regarding instances in which it was unless it meets an articulated therapeutic need necessary to consult with a colleague/manager of the client (for example, disclosing a personal about an uncertain situation (non-client related problem may make the information, such as a letter of summary or client feel as if his/her problems/feelings are being incident report, should be documented on the diminished or that the client needs to help the appropriate confidential form); and nurse); m) considering the cultural values of the client in g) continually clarifying her/his role in the the context of maintaining boundaries, including therapeutic relationship, especially in situations situations that involve self-disclosure and gift in which the client may become unclear about giving. 17 (Walker & Clark, 1999) 18 (Nadelson & Notman, 2002) 19 (Peterneij-Taylor & Yonge, 2003) College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006 8 PR ACTICE STANDARD Giving and accepting gifts the appropriateness of the timing20 (for example, on discharge versus Valentine’s Day), The nurse meets the standard by: the potential for negative feelings on the part of a) abstaining from accepting individual gifts unless, other clients who may not be able to, or choose in rare instances, the refusal will harm the not to, give gifts, and nurse-client relationship. If the refusal could be the monetary value and appropriateness of the harmful, consult with a manager and document gift; and the consultation before accepting the gift; c) giving gifts to clients only as a group of nurses b) accepting a team gift or an individual gift if or from an agency/corporation after determining the refusal of which has been determined to be that: harmful to the therapeutic relationship, only after the client is clear that the nurse does not expect considering: a gift in return; that the gift was not solicited by the nurse, it does not change the dynamics of the that the client is mentally competent, therapeutic relationship; and the client’s intent and expectation in offering there is no potential for negative feelings on the the gift (that is, will the client expect anything part of other clients or toward other members of in return, or will the nurse feel a special the health care team. obligation to that client over others?), 20 (Walker & Clark, 1999) College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006  9 PR ACTICE STANDARD 4) Protecting the client from abuse Nurses protect the client from harm by ensuring that abuse is prevented, or stopped and reported. Indicators his manager the nature of the relationship and decline the assignment of the client); The nurse meets the standard by: f) being cautious about entering into a personal a) intervening and reporting, when appropriate,21 relationship, such as a friendship or romantic incidents of verbal and non-verbal behaviours or sexual relationship, with a former client that demonstrate disrespect for the client; or a former client’s significant other after the b) intervening and reporting behaviours toward a termination of a therapeutic relationship if: client that may be perceived by the client and/or it is determined that such a relationship would others to be violent, threatening or intended by not have a negative impact on the future care of the nurse to inflict physical harm; the client, c) intervening and reporting a health care provider’s the relationship is not based on the trust and behaviours or remarks toward a client that professional intimacy that was developed during may reasonably be perceived by the nurse and/ the nurse-client relationship, and or others to be romantic, sexually suggestive, the client is clear that the relationship is no exploitive and/or sexually abusive;22 longer therapeutic; d) not entering a friendship, or a romantic, sexual or g) not engaging in behaviours toward a client that other personal relationship with a client when a may be perceived by the client and/or others to therapeutic relationship exists; be violent, threatening or intending to inflict e) ensuring that after the nurse-client relationship physical harm; has been terminated, the nurse: h) not engaging in behaviours with a client or must not engage in a personal friendship, making remarks that may reasonably be perceived romantic relationship or sexual relationship by other nurses and/or others to be romantic, with the client or the client’s significant other sexually suggestive, exploitive and/or sexually for one year following the termination of the abusive (for example, spending extra time therapeutic relationship, and together outside of the client’s care plan); may, after one year, engage in a personal i) not exhibiting physical, verbal and non-verbal friendship, romantic relationship or sexual behaviours toward a client that demonstrate relationship with a client (or the client’s disrespect for the client and/or are perceived by significant other) only after deciding that the client and/or others as abusive; such a relationship would not have a negative j) not neglecting a client by failing to meet or impact on the well-being of the client or other withholding his/her basic assessed needs; clients receiving care, and considering the k) not engaging in activities that could result in client’s likelihood of requiring ongoing care or monetary, personal or other material benefit, gain readmission (if the client returns for further care or profit for the nurse (other than the appropriate at the facility, the nurse must declare to her/ remuneration for nursing care or services), the 21 There may be circumstances when a client does not offer his/her consent to share information regarding abuse with the police or other authorities; for example, spousal abuse. 22 The Protecting Patients Act, 2017 (Bill 87) sets out provisions for the mandatory reporting of sexual abuse of a client by a regulated health care provider to the appropriate regulatory college. College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006 10 PR ACTICE STANDARD nurse’s family and/or the nurse’s friends, or result nurse. Should a person for whom the nurse has in monetary or personal loss for the client; and been named power of attorney become a client, l) not accepting the position of power of attorney the nurse must declare to the manager that she/ for personal care or property23 for anyone who is he is the client’s power of attorney and decline or has been a client, with the exception of those the client assignment. clients who are direct family members of the 23 Property includes bank accounts and other financial matters. College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006  11 PR ACTICE STANDARD How To Apply this Standard Decision tree Use this tool to work through a personal situation to client relationship and the behavioural expectations determine whether a particular activity or behaviour contained within this document. The tool may also is appropriate within the context of the nurse-client be useful for self-reflection and peer input as part relationship. The decision tree should be used while of the self-assessment process, and for guiding client considering all of the components of the nurse- care discussions in your practice setting. Proposed behaviour Exploratory questions Is the nurse doing something that the client Meets a clearly identified needs to learn how to do for therapeutic need of the client, himself/herself? rather than a need of the nurse? Can other resources be used For example, is it in the plan of to meet the need? Abstain from care? NO Whose needs are being behaviour* met? YES Will performing the activity cause confusion regarding the nurse’s role? Is the behaviour consistent with Is the employer aware that Abstain from the role of nurses in the setting? NO behaviour* nurses are performing this activity? YES Does the employer have a policy regarding nurses performing this activity? Is this a behaviour you would want Will the employer’s other people to know you had insurance cover the nurse Abstain from engaged in with a client? NO when performing this behaviour* activity? YES Proceed with the behaviour and document it. * Consult with the health care team and manager to determine how to best address the client’s unmet needs. College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006 12 PR ACTICE STANDARD Warning signs of crossing a boundary If the nurse is unable to speak with the colleague There are a number of warning signs that indicate directly or the colleague does not recognize the that a nurse may be crossing the boundaries of the problem, the next step is to speak to the colleague’s nurse-client relationship.24 Nurses need to reflect on supervisor. The nurse should put the concerns in the situation and seek assistance when one or more writing and include the date, time, witnesses and of the following warning signs are present: some type of client identification, such as initials spending extra time with one client beyond his/ or a file number. If the situation is not resolved, her therapeutic needs; further action is needed. This action should include changing client assignments to give care to one informing the client of his/her rights and sending a client beyond the purpose of the primary nursing letter describing the concerns to the next level or the care delivery model; highest level of authority in the agency, or reporting feeling other members of the team do not the matter to CNO. understand a specific client as well as you do; disclosing personal information to a specific If a nurse witnesses another nurse or a member of client; the health care team abusing a client, the nurse must dressing differently when seeing a specific client; take action. CNO research indicates that when frequently thinking about a client when away someone intervenes in an incident of abuse, the from work; abuse stops. After intervening, a nurse must report feeling guarded or defensive when someone any incident of unsafe practice or unethical conduct questions your interactions with a client; by a health care provider to the employer or other spending off-duty time with a client; authority responsible for the health care provider. ignoring agency policies when working with a When an unregulated care provider abuses a client, client; the nurse must intervene to protect the client and keeping secrets with the client and apart from the notify the employer. health care team (for example, not documenting relevant discussions with the client in the health In all cases, the nurse must inform the client of his/ record); her right to contact police. giving a client personal contact information unless it’s required as part of the nursing role; and Certain legislation requires further reporting of a client is willing to speak only with you and abuse. The Regulated Health Professions Act, 1991 refuses to speak with other nurses. requires regulated health professionals to report the sexual abuse of a client by a regulated health When a colleague’s behaviour crosses a professional to the appropriate college. The Child, boundary Youth and Family Services Act, 2017 requires If a nurse believes that a colleague is crossing a reporting suspected child abuse to the Children’s therapeutic boundary, the nurse needs to carefully Aid Society. assess the situation. Address with the colleague: what was observed; how that behaviour is perceived; the impact on the client; and CNO’s practice standards. 24 (Registered Nurses Association of British Columbia, et al., 1995) College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006  13 PR ACTICE STANDARD Maintaining a Quality Practice endeavour to have consistent caregivers and Setting continuity of care to promote the establishment of As partners in care, employers and nurses share trust and comfort; and responsibility for creating an environment that provide nurses with appropriate documentation supports quality practice. These strategies will forms and consultation methods to resolve ethical help employers and nurses develop and maintain and boundary issues. a quality practice setting that supports nurses in providing safe, effective and ethical care. A quality practice setting will: promote reflective practice; support client-centred care; provide resources, including appropriate staffing, to support nurses in establishing therapeutic relationships; provide resources to support the provision of culturally sensitive care; promote positive collegial/interprofessional relations by role modelling and promoting an organizational culture of respect; recognize 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 CNO standards; support staff requesting a change of assignment due to stress or boundary issues; support staff activities that help relieve stress; have expert resources to assist nurses in situations in which establishing a therapeutic relationship is particularly challenging; have zero tolerance for abuse; debrief after critical incidents to provide support to staff and determine the cause, a possible solution and how to prevent a recurrence; have a known procedure for reporting abuse of clients and/or staff members; ensure reports of abuse are investigated and addressed; ensure that proactive visible leadership and clinical supervision is available to support nurses in developing therapeutic relationships and maintaining boundaries; College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006 14 PR ACTICE STANDARD References Peterneij-Taylor, C.A. & Yonge, O. (2003). American Nurses Association. (2001). Code of ethics Exploring boundaries in the nurse- for nurses with interpretive statements.Washington, client relationship: Professional roles and DC: Author. responsibilities. Perspectives in Psychiatric Care, 39(2), 55-66. Bowie, I. (1996). Terms of address: Implications for nursing. Journal of Advanced Nursing, 23(1), 113­ Registered Nurses Association of British Columbia, 119. Council of Licensed Practical Nurses & Registered Psychiatric Nurses Association Forchuk, C., Westwell, J., Martin, M., Bamber- of British Columbia. (1995). Nurse-client Azzapardi, W., Kosterewa-Tolman, D. & Hux, M. relationships: A discussion paper on preventing abuse (2000). The developing nurse-client relationship: of clients and expectations for professional behaviour. Nurses’ perspectives. Nurse Scientist, 6(1), 3-10. Vancouver: Author. Hupcey, J.E., Penrod, J., Morse, J.M. & Mitcham, Registered Nurses’ Association of Ontario. (2002, C. (2001). An exploration and advancement of July). Nursing best practice guideline: Client the concept of trust. Journal of Advanced Nursing, centred care. Toronto: Author. 36(2), 282-293. Smith, L.L., Taylor, B.B., Keys, A.T. & Gornto, Kunyk, D. & Olson, J.K. (2001). Clarification of S.B. (1997). Nurse-patient boundaries: Crossing the conceptualizations of empathy. Journal of the line. American Journal of Nursing, 97(12), Advanced Nursing, 35(3), 317-325. 26-32. Leininger, M. (1996). Culture care theory, research Walker, R. & Clark, J.J. (1999). Heading off and practice. Nursing Science Quarterly, 9(2), boundary problems: Clinical supervision as risk 71-78. management. Psychiatric Services, 50(11), 1435­ 1439. Milton, C.L. (2005). The ethics of respect in nursing. Nursing Science Quarterly, 18(1), World Health Organization. (2001). Solving mental 20-23. health problems. In The world health report – mental health: New understanding, new hope (chap. Nadelson, C. & Notman, M.T. (2002). Boundaries 3). Retrieved February 3, 2006, from www.who. in the doctor-patient relationship. Theoretical int/whr/2001/chapter3/en/index2.html. Medicine and Bioethics, 23(3), 191-201. Newman, C. (2005, Spring). Too close for comfort: Defining boundary issues in the professional- client relationship. Rehab & Community Care Medicine, 7-9. Peplau, H.E. (1991). Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing. New York: Springer. College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006  15 PR ACTICE STANDARD Suggested Reading College of Nurses of Ontario. (2000). Consent practice guideline. Toronto: Author. College of Nurses of Ontario. (2019). Code of Conduct. Toronto: Author College of Nurses of Ontario. (1999). Professional Misconduct document. Toronto: Author. Foster, T. & Hawkins, J. (2005). Nurse-patient relationship. The therapeutic relationship: Dead or merely impeded by technology? British Journal of Nursing, 14(13), 698-702. Gallop, R. (1993). Sexual contact between nurses and patients. Canadian Nurse, 89(2), 28-31. Gaston, C.N. & Mitchell, G. (2005). Information giving and decision-making in patients with advanced cancer: A systemic review. Social Science and Medicine, 61, 2252-2264. McGilton, K.S., O’Brien-Pallas, L.L., Darlington, G., Evans, M., Wynn, F. & Pringle, D.M. (2003). Effects of a relationship-enhancing program of care on outcomes. Journal of Nursing Scholarship, 35(2), 151-156. Registered Nurses’ Association of Ontario. (2002, July). Nursing best practice guideline: Establishing Therapeutic Relationships. Toronto: Author. Sheets, V.R. (2001). Professional boundaries: Staying in the lines. Dimensions of Critical Care Nursing, 20(5), 36-39. College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006 16 PR ACTICE STANDARD Appendix A: Abusive Behaviours sexual intercourse or other forms of sexual contact Abuse can take many forms, including verbal and with a client; and emotional, physical, neglect, sexual and financial. non-physical sexual activity such as viewing Examples of such abusive behaviours are listed pornographic websites with a client. below. Criteria defining who is a client for the purposes of Verbal and emotional includes, but is not sexual abuse: limited to: sarcasm; An individual is a client when there is an interaction retaliation or revenge; between an individual and a nurse, and intimidation, including threatening gestures/ the nurse has issued billings or received payment actions; in connection with a health care service provided teasing or taunting; to that individual, or insensitivity to the client’s preferences; the nurse has contributed to a client record or file swearing; for that individual, or cultural/racial slurs; and the individual has consented to receive a health an inappropriate tone of voice, such as one care service recommended by the nurse, or expressing impatience. a nurse prescribed a drug for which a prescription is needed, to that individual. Physical includes, but is not limited to: hitting; An individual is considered to be a client while pushing; receiving care and for a period of one year following slapping; the end of the professional relationship. shaking; using force; and An individual is not considered a client when: handling a client in a rough manner. the client is receiving professional health care services in an emergency situation, and Neglect includes, but is not limited to: a sexual relationship already exists between the non-therapeutic confining or isolation; individual and the nurse providing the health care denying care; services, and non-therapeutic denying of privileges; there is no reasonable opportunity to transfer care ignoring; and to another qualified health care professional. withholding: ◗ clothing, Financial includes, but is not limited to: ◗ food, borrowing money or property from a client; ◗ fluid, soliciting gifts from a client; ◗ needed aids or equipment, withholding finances through trickery or theft; ◗ medication, and/or using influence, pressure or coercion to obtain the ◗ communication. client’s money or property; having financial trusteeship, power of attorney or Sexual includes, but is not limited to, consensual guardianship; and non-consensual: abusing a client’s bank accounts and credit cards; sexually demeaning, seductive, suggestive, and exploitative, derogatory or humiliating behaviour, assisting with the financial affairs of a client comments or language toward a client; without the health care team’s knowledge. touching of a sexual nature or touching that may be perceived by the client or others to be sexual; College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006  17 PR ACTICE STANDARD Appendix B: Nursing a Family Confidentiality. It is important not to disclose Member or Friend information about a client to other family members In some instances, nurses, especially those working and/or friends without the client’s consent, even in small communities, may be required to care for after the nurse-client relationship has ended. a family member, friend or acquaintance as part of their role. These situations should be limited to circumstances in which there are no other care providers available. The client should be stabilized and, if possible, care transferred. If a nurse’s sexual partner25 is admitted to an agency where the nurse is providing care or services, the nurse must make every effort to ensure that alternative care arrangements are made. Until alternative arrangements are made, however, the nurse may provide care. If it isn’t possible to transfer care, a nurse must consider the following factors. Input from the client. A client may feel uncomfortable receiving nursing services from someone with whom he/she has or had a personal relationship. Self-awareness/reflection. Carefully reflect on whether you can maintain professionalism and objectivity in caring for the client, and whether your relationship interferes with meeting the client’s needs. Also, ensure that providing care to a family member or friend will not interfere with the care of other clients, or with the dynamics of the health care team. Discuss the situation with your colleagues and employer before making a decision. Maintaining boundaries. When providing nursing care for a family member, friend or acquaintance: be aware of the boundary between your professional and personal roles; clarify that boundary for the client; meet personal needs outside of the relationship; and develop and follow a plan of care. 25 If a nurse’s sexual partner is also the nurse’s client, the care could be considered sexual abuse and reported to CNO as outlined in the Regulated Health Professions Act, 1991. College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006 18 PR ACTICE STANDARD Notes: College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006  19 PR ACTICE STANDARD Notes: College of Nurses of Ontario Practice Standard: Therapeutic Nurse-Client Relationship, Revised 2006 101 Davenport Rd. Toronto, ON M5R 3P1 www.cno.org Tel.: 416 928-0900 Toll-free in Canada: 1 800 387-5526 Fax: 416 928-6507 E-mail: [email protected] JUNE 2023 41033 2023-56