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.#
-f 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 (2002). Establishing therapeutic relationships.

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e

# Recommendation 1
The nurse must acquire the necessary knowledge to participate effectively in therapeutic relationships.

# Recommendation 2
Establishment of a therapeutic relationship requires reflective practice. This concept includes the required capacities of: selfawareness, self-knowledge, empathy, awareness of boundaries and limits of the professional role.

# Recommendation 3
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.

# Recommendation 4
All entry-level nursing programs must include in-depth learning about the therapeutic process, including both theoretical content and supervised practice.

# Recommendation 5
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.
Establishing Therapeutic Relationships

# summary of recommendations
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 of Organization & 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 for the assessment tool.

# Recommendation 6
Health care agencies will implement a model of care that promotes consistency of the nurse-client assignment, such as primary nursing.

# Recommendation 7
Agencies will ensure that at minimum, 70 per cent of their nurses are working on a permanent, full-time basis.

# Recommendation 8
Agencies will ensure that nurses' workload is maintained at levels conducive to developing therapeutic relationships.

# Recommendation 9
Staffing decisions must consider client acuity, complexity level, complexity of work environment, and the availability of expert resources.

# Recommendation 10
Organizations will consider the nurse's well-being as vital to the development of therapeutic nurse-client relationships and support the nurse as necessary.

# Recommendation 11
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.

# Recommendation 12
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.

# Recommendation 13
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.

# Recommendation 14
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.
N u r s i n g B e s t P r a c t i c e G u i d e l i n e 10 Establishing Therapeutic Relationships "I find myself, perhaps, listening more intently to my clients now. I find myself using more open-ended questions. I find myself much more easily and quickly gaining their trust and their rapport through them understanding me and where I'm coming from... So the result, for me, certainly was very positive and very rewarding." (Pilot Implementation Site)
Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:
An assessment of organizational readiness and barriers to implementation.
Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process.
Dedication of a qualified individual to provide the support needed for the education and implementation process.
Ongoing opportunities for discussion and education to reinforce the importance of best practices.
Opportunities for reflection on personal and organizational experience in implementing guidelines.
In this regard, RNAO (through a panel of nurses, researchers and administrators) has developed the "Toolkit: Implementation of Clinical Practice Guidelines", based on available evidence, theoretical perspectives and consensus (See Appendix B).

# Responsibility for Guideline Development
The Registered Nurses Association of Ontario (RNAO), with funding from the Ontario Ministry of Health and Long-Term Care, has embarked on a multi-year project to develop, implement, evaluate, and disseminate nursing best practice guidelines.
"Establishing Therapeutic Relationships" is one of seven guidelines developed in the second cycle of the project. The guideline was developed by a panel convened by the RNAO with representation from the practice, research, administration and academic sectors.

# Purpose and Scope
This nursing best practice guideline will address the therapeutic relationship and its central importance to nursing practice. Effective nursing practice is dependent on an effective therapeutic relationship between the nurse and the client. The guideline addresses the qualities and capacities of an effective therapeutic relationship, the state of knowledge, and the knowledge needed to be effective in a therapeutic relationship. To implement a therapeutic relationship successfully, an organization's characteristics and workplace values must be supportive and in place (see Recommendations 5 to 14). The recommendations in this guideline, therefore, focus on practice, education, organization and policy.
The therapeutic relationship is central to all nursing practice. For example, in mental health and community nursing, the therapeutic relationship may be the primary intervention to promote awareness and growth and/or to work through difficulties. In other areas of nursing practice, for example ICU, the therapeutic relationship may be more in the background, serving as the intervention through which comfort, support, and provision of care are facilitated. Regardless of setting and clinical situation, the therapeutic relationship always needs to be established.

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e Guideline Development Process
Chosen by RNAO for their expertise in practice, research and academic sectors, the 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 RNAO. The guideline document was further refined taking into consideration the pilot site feedback and evaluation results as well as current literature.

# Definition of Terms
Clinical Practice Guidelines or Best Practice Guidelines: "Systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific clinical (practice) circumstances" (Field & Lohr, 1990, p. 8). Clinical Practice Guidelines or Best Practice Guidelines are developed using the best available evidence.
Clinical Supervision: "A reflective process that permits supervisees to explore and examine the part they play in the complexities of events within the therapeutic relationship as well as the quality of their practice" (Kelly, Long & McKenna, 2001, p.12). It is an opportunity for personal and professional growth that does not involve penalties or judgement.
Establishing Therapeutic Relationships Education Recommendations: Statements of educational requirements and educational approaches/strategies for the introduction, implementation and sustainability of the best practice guideline.
Evidence: "An observation, fact, or organized body of information offered to support or justify inferences or beliefs in the demonstration of some proposition or matter at issue" (Madjar & Walton, 2001, p. 28).
Organization & Policy Recommendations: Statements of conditions required for a practice setting that enable the successful implementation of the best practice guideline. The conditions for success are largely the responsibility of the organization, although they may have implications for policy at a broader government or societal level.
Practice Recommendations: Statements of best practice directed at the practice of health care professionals that are ideally evidence-based.
Reflective Practice/Self Awareness: The ability to reflect on one's practice, thoughts, feelings, needs, fears, strengths and weaknesses and to understand how these might affect one's actions and the nurse-client relationship.
Stakeholder: A stakeholder is an individual, group or organization with a vested interest in the decisions and actions of organizations who may attempt to influence decisions and actions (Baker et al, 1999). Stakeholders include all individuals or groups who will be directly or indirectly affected by the change or solution to the problem. Stakeholders can be of various types, and can be divided into opponents, supporters and neutrals (Ontario Public Health Association, 1996).

# Therapeutic Relationship:
The therapeutic relationship is grounded in an interpersonal process that occurs between the nurse and the client(s). Therapeutic relationship is a purposeful, goal directed relationship that is directed at advancing the best interest and outcome of the client.

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e Background Context
In preparation of this best practice guideline, a substantive body of literature was reviewed (see Reference & Bibliography sections) and a few highlights are presented here. A large body of literature exists on the nurse-client and therapeutic relationship. In nursing, the therapeutic relationship is called many things: a helping relationship, a purposeful relationship, and the nurse-client relationship. All rest in the notion that effective nursing care is dependent on the nurse coming to know his/her client and engaging in a relationship with that client.
Originally highlighted in the psychiatric nursing literature, the therapeutic relationship has been recognized as fundamental to all nursing (Orlando, 1961;Peplau, 1952;Sundeen, Stuart, Rankin, & Cohen, 1989). Professional nursing organizations have also identified the therapeutic relationship, or helping relationship, as a central piece of nursing care and have embedded qualities of the nurse-client relationship in many of the statements on practice (Canadian Nurses Association, 1980;College of Nurses of Ontario, 1999).
The essential qualities of the therapeutic relationship include respect, empathy and validation.
Many articles have focused on the central importance of empathy in nursing (Gagin, 1983;Olsen, 1991), and research has attempted to capture the particular qualities of empathy in nursing practice (Gallop, Lancee, & Garfinkel, 1990;Reynolds, 2000).
Authors such as Forchuk and colleagues have looked more specifically at the phases and qualities of the therapeutic relationship as defined by Peplau, considering both the nurse and the client perspective in his/her experience of the relationship (Forchuk et al., 1998abcd;Forchuk, Westwell, Martin, Azzapardi, Kosterewa-Tolman & Hux, 2000).
The therapeutic relationship has been identified as an essential component of nursing since the seminal works of Peplau (1952), Tudor (1952) and Orlando (1961). Much of the literature has focused on the elements of the relationship process: the qualities of the relationship; the sequencing of the process; the impediments to the process; and the outcomes of the process. Because of the focus on complexity of this process, there are few clinical trials or studies using randomized samples, to date (Olsen, 1991).

# Establishing Therapeutic Relationships
Qualities of the relationship. The qualities of the therapeutic relationship include: active listening, trust, respect, genuineness, empathy, and responding to client concerns.
Most research has focused on the quality of empathy (Gallop, Taerk, Lancee, Coates, Fanning, & Keatings, 1991;Olsen, 1995;Watt-Watson, Garfinkel, Gallop, & Stevens, 2002). Studies of nurse empathy indicate that empathy is highly valued by nurses and clients (Gallop et al.,1990;Reynolds, 2000).
Sequencing of the process. Recent nursing research has investigated the process of the therapeutic relationship. Forchuk (2000) and others have validated Peplau's (1952Peplau's ( /1988 phases of the therapeutic relationship (orientation, working, resolution), and discovered that some relationships go through a series of phases that are non-therapeutic (orientation, grappling and struggling, mutual-withdrawal). Gallop, Lancee and Garfinkel (1990) have also shown that the interpersonal style of the client can affect the quality of the relationship.
Outcomes of the process. Research evaluating an approach to the therapeutic relationship has found reduced costs and improved quality of life for clients discharged from a psychiatric hospital (Forchuk et al., 1998abc). Preliminary results from a large randomized controlled trial (Forchuk, Hartford, Blomquist, Martin, Chan & Donner, in progress) suggest psychiatric readmissions can be reduced by almost half in the first month after discharge by attending to the development and maintenance of a network of therapeutic relationships. It is believed that these findings in the mental health literature about the importance of therapeutic relationships can be generalized to the broader field of nursing.
Recent health care organizational restructuring has resulted in the removal of significant contextual or organizational elements that support the manifestation of therapeutic relationships. Restructuring has had many impacts such as lower number of professional nurses to patients, replacement of professional with non-regulated health providers, increasing casual and part-time nurses, and decreased support mechanisms such as nurse educators and nurse managers. These impacts have resulted in decreased patient and nurse satisfaction, emotional burnout, increased length of stay (Aiken et al., 2001), decreased quality of care as seen in outcomes such as functional independence, pain, social functioning and patient satisfaction (McGillis Hall et al., 2001).

# Interpretation of Evidence:
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. However, there is a growing body of literature on the impact of the therapeutic process on patient outcomes (Forchuk et al., 1998abc;Frank & Gunderson, 1990;Watt-Watson et al., 2002). It is hoped that this wave of research will allow specific focus on the contribution of nurse-client therapeutic relationship on system outcomes, practice and clinical outcomes. In the meantime, however, the strength of the evidence is based on theoretical concepts, a few qualitative studies, case studies, key reports, clinical expertise and client feedback (see "Background Context" for discussion of evidence).
Establishing Therapeutic Relationships "Also  we won't always be able to give a quick fix for a problem that might come up. I think that was very important for us as nurses to learn, very much so because we always want to give a fix, a quick fix. I mean you feel guilty if you can't solve a problem right away."
(Pilot Implementation Site)

# Practice Recommendations
In preparing the recommendations, the panel developed a Framework For Therapeutic Relationships (See Figure 1). This framework organizes and guides the discussion of the recommendations in the following section as well as provides nurses and health care organizations with a model for understanding the therapeutic relationship. Requisite Knowledge

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e

# Background knowledge

# Knowledge of diversity influences and determinants

# Knowledge of person
Recommendation - 1
The nurse must acquire the necessary knowledge to participate effectively in therapeutic relationships.
Different kinds/fields of knowledge are needed for the nurse to be effective in a therapeutic relationship. There is knowledge that forms the background of all his/her relational practice, and there is knowledge necessary to the specifics of the client.

# 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.

# Knowledge of interpersonal 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)

# 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.
Establishing Therapeutic Relationships

# Knowledge of person.
Knowledge of person is critical and often neglected, due to workplace pressures. The nurse must be supported in finding the time to gain knowledge/understanding of the client in the therapeutic relationship. 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.

# 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;
Standard interventions and issues of rehabilitation;
Pharmacology-in order to administer, monitor, and instruct; and Knowledge of best practices.

# 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.

# 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.
Recommendation - 2
Establishment of a therapeutic relationship requires reflective practice. This concept includes the required capacities of: self-awareness, self-knowledge, empathy, awareness of boundaries and limits of the professional role.
It is possible for the nurse to know him/herself, albeit incompletely, through the process of self-reflection.
Self-knowledge creates the possibility for the nurse to act purposefully, rather than automatically. Thus, a nurse with self-knowledge is able to consider a range of ways of being with the client.
Awareness of his/her potential response options creates opportunity for the nurse to deliberately choose to express thoughts and feelings that are most congruent with the client's needs, goals and values.
The ability of the nurse to engage genuinely and professionally in a relationship with a client helps to create the conditions in which the client's needs are understood, appropriate action is taken, meaning is created, and healing occurs.
The client is a partner in the development of the therapeutic relationship.

# Requisite capacities
- 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.
Empathy is the ability of the nurse to enter into the client's relational world, to see and feel the world as the client sees and feels it, and to explore the meaning it has for the client.
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.
The nurse develops empathy by accessing or imaging within him/herself, certain feelings that are known intuitively to resonate with the client's experience. Note: The nurse does not need to have an identical experience to intuit the feelings and thoughts of the client, nor does he/she have to be in agreement with the client's behaviour to understand the feelings and yearnings that lie below the behaviour. The quality and nature of this feeling is then expressed to the client with the objective of developing and conveying a deep and non-judgmental understanding of the client's experience. In this way, the nurse uses empathy to gain entrance to the client's inner world and to obtain clarity about the client's experience.
Moreover, empathy strengthens the human bond between the nurse and the client as the client comes to feel the comfort of being understood. Vignette: A male nurse on an orthopedic unit is caring for a young woman who has sustained multiple injuries in a motor vehicle accident. The nurse notes that he enjoys providing nursing care for this young woman and that he is particularly gratified when she tells him that he is able to make her more comfortable than the other nurses. He notices that he has begun to "push" to receive this young woman as his "client assignment" and that he feels disappointed when she is assigned to other nurses. Moreover, he has begun to fantasize about her, imagining a situation in which she rejects her boyfriend in favour of him. When providing nursing care for the client, the nurse notices that the client's boyfriend is often "in the way" and that he has resorted to sending him to the waiting room, an intervention he has not seen as being so necessary with other badly injured patients.
Reflecting on his feelings and behaviour towards the young woman and her boyfriend, the nurse realizes that the client makes him feel strong, competent and caring, and that he feels competitive in relation to her boyfriend. Courageously and with integrity, the nurse faces the truth that he is in danger of exploiting the client's vulnerability and placing his personal desires and needs ahead of professional standards and the client's best interests. Accordingly, he requests assignment to a different client and offers to show another nurse how to provide the comfort measures.
Establishing Therapeutic Relationships
The process of developing a therapeutic relationship
Recommendation - 3
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.

# Phases of the therapeutic relationship
Each relationship, although not linear, has a beginning, middle and end. All phases may occur in a single nurse-client encounter or may take place over a number of encounters. Nursing theorist Peplau (1973abcd) refers to these phases as orientation, working and resolution.
Orientation: In the beginning of the therapeutic relationship, the nurse and client are strangers to each other, yet each individual has preconceptions of what to expect -based on previous relationships, experiences, attitudes and beliefs (Peplau, 1952). The parameters of the relationship are established (e.g., place of meeting, length, frequency, role or service offered, confidentiality, duration of relationship). The client and nurse begin to learn to trust and know each other as partners in the relationship. Trust, respect, honesty and effective communication are key principles in establishing a relationship.
Accepting the client is important for the evolvement of the nurse-client relationship (McKlindon & Barnsteiner, 1999;Thomas, 1970). 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.
Vignette: A 13-year-old female comes to the nurse's office in the public school. The nurse has never met the student before. The student is quiet, withdrawn and appears on the verge of crying. She tells the nurse she wants some information on how not to get pregnant. The nurse responds by:
Conveying an open and non-judgmental attitude;
Introducing him/herself by name and designation;
Explaining his/her role and the services he/she can offer;

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e
Addressing the issue of confidentiality;
Encouraging the client to talk and ask questions;
Listening attentively so that he/she can offer comfort and support, and reduce the client's anxiety and tension;
Assisting the client to identify concerns/needs; and
Being aware of his/her own feelings, values related to sexuality, early sexual experimentation and how this may affect the relationship 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).
It is important for the nurse to validate thoughts, feelings and behaviours (Orlando, 1961). 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.
Vignette: The psychiatric nurse care-manager has been seeing a 32-year old male client for the past two years. The client was diagnosed with schizophrenia and has experienced a reduction in symptoms over the past year. The nurse and the client are working on the goal of greater independence. The client's priority is to move from the group home to an apartment.

# The nurse responds by:
Supporting the client's problem solving by examining with the client, alternatives and criteria for the new accommodation;
Discussing the skills required for independent living and how these skills may be enhanced/developed; Encouraging the client to do "homework" by seeking out information and then discussing this with the nurse;
Being aware of his/her own desire to be a "helper" and the potential conflict with the client's need to help himself.
Establishing Therapeutic Relationships
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).
Both the nurse and the client experience growth (Peplau, 1989;Sundeen et al., 1989). Termination may be met with ambivalence. The nurse and the client must recognize that loss may accompany the ending of a relationship (Sundeen et al., 1989). 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).
Vignette: A 72-year-old male client is being discharged from a stroke rehabilitation in-patient program. The nurse has worked with the client and his family over the past couple of months.
A pressing concern is planning for in-house supports and discussing community resources that have now been accessed. The final meeting is planned between the nurse and client to review the progress that has been made and the future plans. Both use this opportunity to say their good-byes. They are both aware of ambivalent feelings-happiness at the progress made and return to home, yet some sadness at the loss of a comfortable and familiar relationship.

# Responding to difficulties in the relationship
The nurse and the client need to be able to respond to concerns at any phase in the relationship.
Boundaries are maintained with the understanding that the purpose of the relationship is to meet the therapeutic needs of the client. If the relationship does not develop therapeutically, the nurse needs to seek information from the client and consultation from others. A change in the nurse-client relationship assignment may be necessary.
The nurse needs to be aware of and use patterns of interaction and relation that promote client growth and health. Communication techniques between nurse and client can include: listening, silence, open-ended questions and statements, restating, reflecting, seeking clarification and validation, focusing, summarizing, awareness of verbal and non-verbal communication, and awareness of cultural differences related to communication.

# Basic nursing education

# Recommendation - 4
All entry-level nursing programs must include in-depth learning about the therapeutic process, including both theoretical content and supervised practice.
Nursing education provides the foundational knowledge required to establish nurse-client therapeutic relationships at the beginner level. Educational development in the area of therapeutic relationships is needed for nurses in all specializations and practice settings to provide additional background, expertise in obtaining knowledge of the client, and knowledge of self. The student nurse needs to observe expert practitioners working with clients, as well as have expert practitioners observe him/her in clinical practice, who will then assist to develop the student's interpersonal skills.
Establishing Therapeutic Relationships Education Recommendations "...here was a real sensibility to be able to look at things from the perspective of the other, to be able to honestly examine oneself and one's actions, to look at actions and recognize that, even though... you could have had certain intentions,... intentions aren't necessarily understood, and that just to be well intentioned doesn't mean that you don't cause harm... just real openness to looking at a situation from every perspective." (Pilot Implementation Site)

# Professional development
Recommendation Principles of engaging, maintaining and terminating relationships;
Core concepts of therapeutic relationships such as reciprocity, self-awareness, boundaries, trust, empathy and confidentiality;
The content areas outlined in the framework for understanding the therapeutic relationship as seen in Figure 1.
Continuing education, with respect to therapeutic relationships, begins at organization/ institution orientation and continues to be regularly integrated into nursing practice over time.
Institutions will expect nurses to participate in learning opportunities.
N u r s i n g B e s t P r a c t i c e G u i d e l i n e Key Learning Strategies:

# Clinical supervision Coaching Group exercises Demonstration interviews Role modeling Case consultation
Establishing Therapeutic Relationships
The characteristics of organizations and agencies that provide health care will influence the development of a therapeutic relationship between the nurse and the client. Clients have a right to a therapeutic relationship and organizations have a responsibility to enable the client and the nurse to develop and maintain a relationship. These organizational characteristics are best described as "necessary, though insufficient" for the development of therapeutic relationships. Without these characteristics, it is unlikely that a therapeutic relationship will occur. However, these characteristics alone will not guarantee a therapeutic relationship.
In the next section, some important characteristics will be described and guidelines will be identified that will enable an organization to support the development of therapeutic relationships.

# Organizational & Policy Recommendations
"It changed in the sense that I try to listen more, and, with the various cultures, try to be sensitive to their needs. That isn't always easy because... you're just in and out of a room like a butterfly."
(Pilot Implementation Site)

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e
The organization and organizational characteristics

# Continuity of care and caregiver

# Recommendation - 6
Health care agencies will implement a model of care that promotes consistency of the nurse-client assignment, such as primary nursing.
The nurse and the client need the opportunity to develop an awareness of, and a familiarity with, one another. Models of care that facilitate a greater continuity of care and caregiver provide the opportunity for a trusting relationship to form.
In the hospital sector, total client care and primary nursing have been identified as models that facilitate professional staff autonomy, flexibility and cohesiveness among staff (Massaro et al., 1996).
Primary nursing, in particular, has been identified as a preferred model to enhance quality of client care, increase the satisfaction of clients, increase job satisfaction of nurses and physicians, and decrease absenteeism (Blenkham, D'Aico, & Virtue, 1988;Buchan, 1999;Mason, 2000;Sovie, 1983).

# Recommendation - 7
Agencies will ensure that at minimum, 70 per cent of their nurses are working on a permanent, full-time basis.
Having nursing staff employed on a casual basis is a key contributor of nurse dissatisfaction.
Over the past several years, many agencies moved to "increase their flexibility" through the "casualization" of nursing care. Permanent, full-time positions have been reduced and casual and part-time positions have increased (Baumann et al., 2001;RNAO, 2000;RNAO, 2001). As a result, client care has become fragmented and the nurse's satisfaction in being able to assist clients through an entire recovery process has been lost, thus, leaving clients dissatisfied and nurses frustrated. The development and maintenance of a therapeutic relationship is hampered when the nurse is working on a casual basis. The panel recommends organizations target having 70 per cent full time nursing staff in order to return to the pre-restructuring period in Ontario. This recommendation has been endorsed by the "Nursing Task Force" and the Joint Provincial Nursing Committee (two prominent groups in Ontario) (J. Choiniere, personal communication, April 16, 2002).

# Time for care

# Recommendation - 8
Agencies will ensure that nurses' workload is maintained at levels conducive to developing therapeutic relationships.
With the increased acuity across all sectors, workload has increased significantly. A persistently high workload is not sustainable for the nurse, highly unsatisfactory for clients, and incompatible with therapeutic relationships. Support is required by administrative and managerial levels to ensure the nurse has adequate time to engage in the therapeutic process. Several studies have shown that inadequate nurse to patient ratios are associated with adverse outcomes such as complications and increased resource use (Dimick, Swoboda, Pronovost & Lipsett, 2001;Pronovost et al., 2001) and decreased patient satisfaction (McGillis Hall et al., 2001). Additionally, a large retrospective study by Tourangeau, Giovannetti, Tu and Wood (2002) found nursing skill mix (number of registered nurses compared to less qualified nursing personnel) and nurses' years of experience associated with increased 30-day mortality for hospitalized patients. That is, better mortality outcomes were associated with a skill mix that included a richer registered nurse composition as well as with more experienced registered nurses.
Establishing Therapeutic Relationships "The one area that I heard a lot of the facilitators talking about was the whole area of the nurse doing more selfreflection and being more self-aware about the care that they were giving, like whether they were actually engaging the person." (Pilot Implementation Site)
Matching patient complexity with appropriate clinical expertise

# Recommendation - 9
Staffing decisions must consider client acuity, complexity level, complexity of work environment, and the availability of expert resources.
Widespread de-skilling of client care has occurred over the past few years with the replacement of registered nurses and registered practical nurses with unregulated care providers.
This is occurring at the same time that client acuity has increased in all sectors. Care needs in the community sector have increased dramatically (Price Waterhouse Coopers, 2000). Some Community Care Access Centres, in particular, have reported an increase in acuity of 20 to 30 percent (RNAO, 2000). In acute care hospitals, fewer beds and a decreased length of client stay mean that those who remain in hospital are sicker and require more complex care (Ontario Hospital Association, 1999;RNAO, 2000).
Clients in long-term care facilities today are older, frailer, and have more complex health care needs than ever before (Price Waterhouse Coopers, 2001). It is important that the level of knowledge and skills of those providing care is adequate and appropriate for the complexity of client need. Yet, the level of knowledge and skills of those providing their care is lower.
A 1995 study of the long-term care sector for the Ontario Ministry of Health and Long-Term Care showed that 75 per cent of staff reported having insufficient time to deal with clients' health care needs (O'Brien-Pallas et al., 1995). This reality has made the job of providing quality, holistic care more difficult, if not an impossible goal.

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e
It is essential that the knowledge and expertise of the nurse match the acuity of client need. Without this match, the provider is unable to offer the level of care needed and the client is unable to optimize his/her health status. The mismatch of nursing knowledge and expertise with care needs may create a barrier to establishing therapeutic relationships.

# Prevention of stress and burnout

# Recommendation - 10
Organizations will consider the nurse's well-being as vital to the development of therapeutic nurse-client relationships and support the nurse as necessary.
Maintaining an effective nurse-client relationship in increasingly acute, complex and, at times, violent surroundings are emotionally and often physically demanding for the nurse.
Promoting and monitoring nurses' emotional health is critical to effectively engaging and maintaining optimal therapeutic relationships.
Literature on magnet hospitals in the USA emphasizes that caring of nurses leads to significantly lower rates of nurse-burnout (Scott, Sochalski, & Aiken, 1999). Magnet hospitals support the wellbeing of the nurse and therefore have higher nursing retention rates, satisfaction, and improved client outcomes. Organizations that support the well-being of the nurse must make various strategies available for addressing job-related stress.
Establishing Therapeutic Relationships "These are very skilled nurses and they tend to forget that because they're suffering so much from feelings of being under-valued. So it's made a huge difference in that sense.
It gave them a real boost."
(Pilot Implementation Site) N u r s i n g B e s t P r a c t i c e G u i d e l i n e

# Recommendation - 11
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.
To effectively develop and maintain therapeutic relationships, the nurse needs to be aware of current knowledge generated in this area. Research in the area of the therapeutic relationship needs to be continuously generated and disseminated. Research needs to consider process and outcome measures; nurse and client perspectives; and could be quantitative or qualitative in nature. Evidence-based practices need to be promoted and disseminated across organizations in a timely fashion.

# Nursing leadership

# Recommendation - 12
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.
Nursing leadership that is stable, visible, highly accessible, and fosters frequent and open communication between the nurse and senior managers, creates an environment that supports the creativity, innovation, risk-taking and trust required to develop and maintain therapeutic relationships.

# Establishing Therapeutic Relationships
Clinical supervision and coaching

# Recommendation - 13
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.
Interpersonal skills can only be fully acquired or developed by interpersonal processes such as clinical supervision, coaching, role modeling and peer supervision. To accomplish this, nursing leaders must allocate financial resources within the budget to cover the cost of clinical supervision and coaching. A staffing mix that includes ongoing clinical supervision and coaching by a senior clinician would help nurses to identify their own professional strengths and weaknesses. Such a senior clinician needs to have experience, education, and ability to facilitate objective self-evaluation. This process is enhanced if the clinical supervision is provided by a clinician with no administrative authority over the nurse.
"In these years of nursing, in the current nursing crisis etc., we really need to pull together and strive to maintain morale... We not only need to get the job done out there but we need to support each other and listen to each other and praise each other and I think this was a wonderful opportunity to do that." (Pilot Implementation Site)
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.
Over time, it is expected that all health care agencies, professional bodies and accreditation bodies will work towards incorporating the therapeutic relationship and all other best practice guidelines into their accreditation standards.
Nursing best practice guidelines can be successfully implemented only where there is adequate planning, resources, organizational and administrative support, as well as the appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:
An assessment of organizational readiness and barriers to education.
Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process.
Dedication of a qualified individual to provide the support needed for the education and implementation process.
Ongoing opportunities for discussion and education to reinforce the importance of best practices.
Opportunities for reflection on personal and organizational experience in implementing guidelines.
In this regard, RNAO (through a panel of nurses, researchers and administrators) has developed the "Toolkit: Implementation of Clinical Practice Guidelines", based on available evidence, theoretical perspectives and consensus (See Appendix B).

# Establishing Therapeutic Relationships Evaluation & 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. The following
- To evaluate the impact of implementation of the recommendations.
- Knowledge acquisition measures relating to therapeutic relationship theory, and therapeutic relationship process: Assessment of current baseline knowledge Post-educational session level of knowledge Retention of knowledge - Nurses' self report on their comfort with establishing therapeutic relationships.
- Nurses' satisfaction.
- Client satisfaction measures.
- Number of complaints/ compliments.
- Length of stay.
- Readmission rates.
- Overall resource utilization.
- To evaluate the supports available in the organization that allow for nurses to have therapeutic relationships with their clients.
- Does the model of care delivery facilitate continuity of care & caregiver?
- Availability of clinical experts.
- Availability of experts for clinical supervision and coaching.
- Number of professional to unregulated nursing staff.
- Per cent of full time professional nursing staff.
- Nurse to client ratio.
- Availability of education.
- Per cent of nurses attending educational opportunities.
- Client acuity levels.
- Nursing turnover costs.

# 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 (Edwards, Davies & Hunt, 2002;Gallop, Lancee & Garfunkel, 1989). 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). The responses were coded using a scoring tool from Gerrard, Boniface and Love (1980) 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.
N u r s i n g B e s t P r a c t i c e G u i d e l i n e

# Process for Update/Review of Guideline
The Registered Nurses Association of Ontario proposes to update the nursing best practice guidelines as follows:
- Following dissemination, each nursing best practice guideline will be reviewed by a team of specialists (Review Team) in the topic area every three years following the last set of revisions.
- During the three-year period between development and revision, RNAO Nursing Best Practice Guidelines project staff will regularly monitor for new research, systematic reviews and randomized control trials.
- Based on the results of the monitor, project staff may recommend an earlier revision period.
Appropriate consultation with a team of members comprising original panel members and other specialists in the field will help inform the decision to review and revise the guideline earlier than the three-year milestone.
- Three months prior to the three-year review milestone, the project staff will commence the planning of the review process as follows:
a. Invite specialists in the field to participate in the Review Team. The Review Team will be comprised of members from the original panel as well as other recommended specialists.  The following definition will be added to those in the "Definition of Terms" section starting on page 12 of the guideline.

# Definition Intentionality
Our intentions remind us of what is important and inform our choices and actions. Thinking related to intentionality connects with the concepts of consciousness and energy. For example, if our conscious intentionality is to hold thoughts that are caring...in contrast to having thoughts to control and have power over, the consequence will be different based on the different levels of consciousness and the energy associated with different thoughts (Watson, 2005).
Changes made to the Framework for Therapeutic Relationships -Figure 1 are highlighted below:
Requisite Capacities for Establishing Therapeutic Relationships
Phases of Therapeutic Relationship

# Appendix A

# Organizational Readiness Assessment Worksheet
It is recommended that you assess the work environment for its readiness to support the implementation of the nursing best practices guideline on establishing therapeutic relationships.
Without strong work environment support, your efforts to implement the guideline will be greatly hampered. This worksheet 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. You may find up-front work on identifying the barriers and addressing these prior to guideline implementation very beneficial. Some strategies can be worked on parallel to the implementation process.
Answer the questions related to each of the recommendation elements in the table on page 48.
Using a group of people to assess the work environment will give you diverse perspectives.
Identify actions/strategies to address elements not met or partially met.
Identify stakeholders who need to be engaged to assist in meeting the requirements under each element.
Set target timelines to meet the requirements.

# Establishing Therapeutic Relationships

# Recommendation Element Met

# Appendix B

# Toolkit: Implementation of Clinical Practice Guidelines
Nursing best practice guidelines can only be successfully implemented if there are: adequate planning, resources, organizational and administrative support as well as appropriate facilitation.
In this light, RNAO, through a panel of nurses, researchers and administrators, has developed the "Toolkit: Implementation of 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:
- Identifying a well-developed, evidence-based clinical practice guideline.
- Identification, assessment and engagement of stakeholders.
- Assessment of environmental readiness for guideline 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.

# Establishing Therapeutic Relationships
The "Toolkit" is available through the Registered Nurses Association of Ontario. The document is available in a bound format for a nominal fee, and is also available free of charge off the RNAO website. For more information, an order form or to download the "Toolkit", please visit the RNAO website at www.rnao.org.

# Appendix C
Example of Scenarios for Evaluation of Nurses' Knowledge of the Therapeutic Relationship (Edwards et al., 2002) A promising methodology was used to evaluate the process of practice change, involving a "reader" presenting scenarios to the nurse. The scenarios reflected situations, as closely as possible, to those encountered by the nurse in daily practice.

# Instructions to reader of scenarios and client statements
Read the instructions slowly to the nurse who is participating in this study. Each scenario begins by describing a hypothetical situation and is followed by several narrative statements. Your job is to read the scenario and the individual narrative statements allowing for responses by the nurse who is being tested in this study. After each narrative statement in the scenario you must pause to allow the nurse time to respond into the tape recorder in a natural manner. Only after the nurse has finished her response should you move to the next narrative statement. Let the nurse know when you are starting a new scenario. There are a total of "x" scenarios in this exercise.

# Instructions to participants
Imagine that you are working on your maternity unit/in the community. I will describe several hypothetical client situations. All patients are postpartum mothers. After describing each hypothetical situation, I will read several statements made by the client on separate occasions. These are typical statements you might hear from a client. The statements made by each client are not connected in any way. After each statement, I will ask you to respond to the client's statement. Respond as naturally and as quickly as you can. You will be asked to speak into a tape recorder. Talk out loud as though you are responding to the patient. There are no right or wrong answers.

# One example of a scenario
Tracy is a 16 year-old primip. She had a caesarian section and delivered twins four days ago. Her boyfriend has not visited her in hospital.

# While under your care, this patient says:
"I don't know how I'm going to manage with these babies all by myself." "I'm sure my boyfriend is coming to visit tomorrow. He's just been way too busy to get here." "My friends think having twins is a big deal. I think it sucks." "I can't look after the babies today. I hurt too much from my operation." "I don't need a nurse to visit me at home."

# N u r s i n g B e s t P r a c t i c e G u i d e l i n e