• Registered Nurses Association of Ontario (RNAO). Establishing therapeutic relationships supplement. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2006 Mar. 6 p. [28 references]



• Registered Nurses Association of Ontario (RNAO). Establishing therapeutic relationships. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2002 Jul. 54 p. [66 references]

This is the current release of the guideline.

Any disease or condition requiring a nurse's care

Counseling
Management

Family Practice
Nursing
Psychology

Advanced Practice Nurses
Health Care Providers
Nurses

To present nursing best practice guidelines for establishing therapeutic relationships with clients (i.e. to address the qualities and capacities of an effective therapeutic relationship, the state of knowledge, and the knowledge needed to be effective in a therapeutic relationship)

Canadian clients in the health care setting

1. Acquiring requisite knowledge for establishing therapeutic relationships (i.e. background knowledge; knowledge of interpersonal, caring, and development theory; knowledge of diversity influences and determinants; knowledge of person; knowledge of health/illness; knowledge of broad influences on health care and health care policy; knowledge of systems)
2. Acquiring requisite capacities for establishing therapeutic relationships (i.e. self-awareness; self-knowledge; empathy; awareness of ethics, boundaries, and limits of professional role)
3. Recognizing the current phase of therapeutic relationships with clients (i.e. beginning phase/orientation; middle or working phase; ending or resolution phase)
4. Education, organization, and policy strategies and approaches

Effectiveness of interventions at helping nurses establish therapeutic relationships with clients

Searches of Electronic Databases

The guideline developers and revision panel conducted an extensive literature search and reviewed theoretical concepts, qualitative, case studies, and key reports.

July 2002 Guideline

Not stated

March 2006 Supplement

Seventy-nine (79) articles were retrieved for review.

Expert Consensus

Not applicable

Review

Not stated

Expert Consensus

July 2002 Guideline

Chosen by the Registered Nurses Association of Ontario (RNAO) for their expertise in practice, research and academic sectors, the Guideline Development Panel defined the purpose and scope of the guideline on establishing therapeutic relationships, defined the terminology, conducted an extensive literature search, provided a background context, developed recommendations, and sought various stakeholders' feedback.

In preparing the practice recommendations, the panel developed a Framework for Therapeutic Relationships (see Figure 1 in the original guideline document). This framework organizes and guides the discussion of the recommendations as well as provides nurses and healthcare organizations with a model for understanding the therapeutic relationship.

March 2006 Supplement

RNAO has made a commitment to ensure that this practice guideline is based on the best available evidence. In order to meet this commitment, a monitoring and revision process has been established for each guideline every three years. The revision panel members (experts from a variety of practice settings) are given a mandate to review the guideline focusing on the recommendations and the original scope of the guideline.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Clinical Validation-Pilot Testing
External Peer Review

The draft nursing best practice guideline was pilot tested over an eight-month period in several organizations in Ontario that were identified through a "request for proposal" process conducted by Registered Nurses Association of Ontario (RNAO). The guideline document was further refined taking into consideration the pilot site feedback and evaluation results as well as current literature.

Pilot Implementation Evaluation Methodology

During the pilot implementation of the guideline on Establishing Therapeutic Relationships, a unique and promising methodology was used to evaluate the process of practice change. The following describes the methodology that readers may want to consider as an example of evaluating changes in the nurse-client therapeutic relationship.

Measures included a pre and post measure of active listening, initiating and assertiveness. The methodology involved presenting nurses with context relevant scenarios that were previously validated with a panel of experts. It was noted that it was important to present scenarios that were as close as possible to the types of situations that nurses are exposed to in real life. Nurses were presented with scenarios by an interviewer and asked to respond to several questions (see example of scenarios in Appendix C of the original guideline document). The responses were coded using a scoring tool to identify scores for the three identified variables (active listening, initiating and assertiveness). This methodology showed that it is possible to evaluate the changes in nurses' behaviours with respect to the qualities of a therapeutic relationship.

Note from the National Guideline Clearinghouse (NGC): In March 2006, the Registered Nurses Association of Ontario amended the current practice recommendations for this topic. Through the review process, no recommendations were added or deleted, however one recommendation was reworded to reflect new knowledge. The recommendations have been noted below as "changed" or "unchanged."

The Guideline Development Panel for the nursing best practice guideline for "Establishing Therapeutic Relationships" strongly urges organizations or practice settings to pay considerable attention to the recommendations under the heading Organization and Policy Recommendations (see Recommendations 5 to 14). Implementation of strategies to support the establishment of the therapeutic relationships between nurses and clients requires strong organizational support. Without such support, the journey towards meeting therapeutic relationship goals will be difficult. The Panel recommends organizations/practice settings conduct an organizational readiness assessment, plan and commence implementing initiatives that will establish the desirable supports. An organizational readiness assessment tool has been developed based on the recommendations in this guideline. See Appendix A in the original guideline document for the assessment tool.

Practice Recommendations

Requisite Knowledge

Recommendation 1 (Unchanged)

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

Reflective Practice/Self-Awareness

Recommendation 2 (Changed March 2006)

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

Recommendation 3 (Unchanged)

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.

Education Recommendations

Basic Nursing Education

Recommendation 4 (Unchanged)

All entry-level nursing programs must include in-depth learning about the therapeutic process, including both theoretical content and supervised practice.

Professional Development

Recommendation 5 (Unchanged)

Organizations will consider the therapeutic relationship as the basis of nursing practice and, over time, will integrate a variety of professional development opportunities to support nurses in effectively developing these relationships. Opportunities must include nursing consultation, clinical supervision and coaching.

Organizational and Policy Recommendations

Continuity of Care and Caregiver

Recommendation 6 (Unchanged)

Health care agencies will implement a model of care that promotes consistency of the nurse-client assignment, such as primary nursing.

Recommendation 7 (Unchanged)

Agencies will ensure that at minimum, 70 percent of their nurses are working on a permanent, full-time basis.

Time for Care

Recommendation 8 (Unchanged)

Agencies will ensure that nurses' work-load is maintained at levels conducive to developing therapeutic relationships.

Matching Patient Complexity with Appropriate Clinical Expertise

Recommendation 9 (Unchanged)

Staffing decisions must consider client acuity, complexity level, complexity of work environment, and the availability of expert resources.

Prevention of Stress and Burnout

Recommendation 10 (Unchanged)

Organizations will consider the nurse's well-being as vital to the development of therapeutic nurse-client relationships and support the nurse as necessary.

Evidence-Based Practice

Recommendation 11 (Unchanged)

Organizations will assist in advancing knowledge about therapeutic relationships by disseminating nursing research, supporting the nurse in using these findings, and supporting his/her participation in the research process.

Nursing Leadership

Recommendation 12 (Unchanged)

Agencies will have a highly visible nursing leadership that establishes and maintains mechanisms to promote open conversation between nurses and all levels of management, including senior management.

Clinical Supervision and Coaching

Recommendation 13 (Unchanged)

Resources must be allocated to support clinical supervision and coaching processes to ensure that all nurses have clinical supervision and coaching on a regular basis.

Accreditation

Recommendation 14 (Unchanged)

Organizations are encouraged to include the development of nursing best practice guidelines in their annual review of performance indicators/quality improvement, and accreditation bodies are also encouraged to incorporate nursing best practice guidelines into their standards.

None provided

Recommendations are based on the evaluation of theoretical concepts, a few qualitative studies, case studies, key reports, clinical expertise and client feedback. In gathering and critically appraising the literature, the panel concluded that there were no systematic reviews of randomized controlled trials or other research designs, related to the therapeutic relationships.

• Guideline implementation is intended to help nurses establish therapeutic relationships with clients.
• Nurses, other health care professionals and administrators who are leading and facilitating practice changes will find this document valuable for the development of policies, procedures, protocols, educational programs, assessment and documentation tools, etc.

Not stated

• These best practice guidelines are related only to nursing practice and not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to accommodate client/family wishes and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor Registered Nurses Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products.
• In gathering and critically appraising the literature, the panel concluded that there were no systematic reviews of randomized controlled trials or other research designs, related to the therapeutic relationship mainly because of the limited review of studies evaluating process or outcomes of therapeutic relationships.
• The March 2006 supplement to the nursing best practice guideline Establishing Therapeutic Relationships is the result of a three year scheduled revision of the guideline. Additional material has been provided in an attempt to provide the reader with current evidence to support practice. Similar to the original guideline publication, this document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. This supplement should be used in conjunction with the guideline as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.

Organizational Readiness Assessment

A worksheet (found in Appendix A of the original guideline document) has been developed to assist in assessing for strengths in the work environment as well as plan out strategies prior to spending time and resources with the guideline implementation.

Toolkit: Implementing Clinical Practice Guidelines

Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as the appropriate facilitation. In this regard, Registered Nurses Association of Ontario (RNAO) (through a panel of nurses, researchers and administrators) has developed The Toolkit for Implementing Clinical Practice Guidelines, based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a health care organization.

The "Toolkit" provides step by step directions to individuals and groups involved in planning, coordinating, and facilitating the guideline implementation. Specifically, the "Toolkit" addresses the following key steps:

1. Identifying a well-developed, evidence-based clinical practice guideline
2. Identification, assessment and engagement of stakeholders
3. Assessment of environmental readiness for guideline implementation
4. Identifying and planning evidence-based implementation strategies
5. Planning and implementing evaluation
6. Identifying and securing required resources for implementation

Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a complex undertaking. The "Toolkit" is one key resource for managing this process.

A current ongoing investigation related to implementation strategies for an intervention based on therapeutic relationships has found the following to be important:

• Ongoing champions to provide personal level support
• Program specific training related to therapeutic relationships which includes discussion of specific examples
• Documentation systems that support the intervention

The Culturally Responsive Therapeutic Relationship (CRTR) project is a project that has received funding from the Change Foundation with a focus on integration of the RNAO guideline Establishing Therapeutic Relationships and the standards produced by the College of Nurses of Ontario specific to culturally sensitive care. Lessons learned from CRTR project include the following:

• Need to find ways to promote reflective practice with nursing staff
• Need for recognition of one's self awareness with respect to one's own privilege. It is not enough to know your own biases, but also to be aware of how others might see you
• Need for discussion regarding disclosure, boundaries and reciprocity in a therapeutic relationship

For other specific recommendations regarding implementation of this guideline, refer to the "Major Recommendations" field.

Evaluation and Monitoring

Organizations implementing the recommendations in this nursing best practice guideline are recommended to consider how the implementation and its impact will be monitored and evaluated. A table (found in the original guideline document) based on framework outlined in the RNAO Toolkit for Implementation of Clinical Practice Guidelines (2002), illustrates some indicators for monitoring and evaluation.

End of Life Care
Getting Better
Living with Illness
Staying Healthy

Effectiveness
Patient-centeredness

• Registered Nurses Association of Ontario (RNAO). Establishing therapeutic relationships supplement. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2006 Mar. 6 p. [28 references]



• Registered Nurses Association of Ontario (RNAO). Establishing therapeutic relationships. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2002 Jul. 54 p. [66 references]

Not applicable: The guideline was not adapted from another source.

2002 Jul (addendum released 2006 Mar)

Registered Nurses' Association of Ontario - Professional Association

Funding was provided by the Ontario Ministry of Health and Long Term Care.

Not stated

Revision Panel Members

Cheryl Forchuk, RN, PhD
Team Leader
Professor, University of Western Ontario
Scientist, Lawson Health Research
Institute/London Health Sciences Centre
London, Ontario

Kathleen Carmichael, BScN, MScN
Professor of Nursing
Fanshawe College
London, Ontario

Gabriella Golea, RN, MN, CPMHN (C)
Administrative Director
Centre for Addictions and Mental Health
Toronto, Ontario

Nancy Johnston, RN, PhD
Associate Professor
Atkinson Faculty of Liberal &
Professional Studies
School of Nursing, York University
Toronto, Ontario

Mary-Lou Martin, RN, MEd MScN
Clinical Nurse Specialist
St. Joseph's Healthcare
Associate Clinical Professor
McMaster University
Hamilton, Ontario

Patricia Patterson, RN, BScN, MA, CPMHN (C)
Professor, Nursing Division
Fanshawe College
London, Ontario

Karen Ray, RN, MSc
Research Manager
Saint Elizabeth Health Care
Markham, Ontario

Trish Robinson, RN, BScN, DBS (dip), Med
Outreach Mental Health Coordinator
St. Michael's Hospital
Toronto, Ontario

Selinah Adejoke Sogbein, RN, BScN, MHA, MEd
CHE, CPMHN (C)
Chief Nursing Officer
North East Mental Health Centre
North Bay, Ontario

Rani Srivastava, RN, MScN, PhD (cand.)
Deputy Chief of Nursing Practice
Centre for Addiction and Mental Health
Toronto, Ontario

Tracey Skov, RN, BScN, MSN (cand.)
Program Coordinator
Nursing Best Practice Guideline Program
Registered Nurses' Association of Ontario
Toronto, Ontario

Contributor
Pat Bethune - Davies, RN, BScN, MScN
Professor of Nursing
Western-Fanshawe Collaborative BScN Program
London, Ontario

The Registered Nurses Association of Ontario (RNAO) received funding from the Ministry of Health and Long-Term Care (MOHLTC). This guideline was developed by a panel of nurses and researchers convened by the RNAO and conducting its work independent of any bias or influence from the MOHLTC.

This is the current release of the guideline.

This NGC summary was completed by ECRI on December 17, 2003. The information was verified by the guideline developer on January 16, 2004. This NGC summary was updated by ECRI on June 22, 2006.

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses' Association of Ontario (2006). Establishing Therapeutic Relationships. (rev. suppl.) Toronto, Canada: Registered Nurses' Association of Ontario.