CNO - Therapeutic Nurse Client Relationship

Question 1

Protect the public’s right to quality nursing services by

providing leadership to the nursing profession in self-regulation.

Answer 1

The CNO’s Mission

Question 2

Excellence in nursing practice everywhere in Ontario.

Answer 2

The CNO’s vision

Question 3

Nursing ___ are expectations that contribute to public protection.

Answer 3

standards

Question 4

They inform nurses of their accountabilities and the public of what to expect of nurses.

Answer 4

Nursing standards

Question 5

Apply to all nurses regardless of their role, job description, or area of practice.

Answer 5

Nursing standards

Question 6

There are five components to the ___-___ relationship: trust, respect, professional intimacy, empathy, and power.

Answer 6

nurse-client

Question 7

Critical in the nurse-client relationship because the client is in a vulnerable
position. Initially, it in a relationship is fragile, so it’s especially important that a nurse keep promises to a client.

Answer 7

Trust

Question 8

If it is breached, it becomes difficult to re-establish.

Answer 8

Trust

Question 9

The recognition of the inherent dignity, worth, and uniqueness of every individual,
regardless of socio-economic status, personal attributes and the nature of the health problem.

Answer 9

Respect

Question 10

Inherent in the type of care and services that nurses provide. It may relate to the physical activities, such as bathing (which nurses perform), and with the client that creates closeness.

Answer 10

Professional intimacy

Question 11

Professional
intimacy can also involve psychological, spiritual
and social elements that are identified in the plan
of care. Access to the client’s personal information,
within the meaning of the Freedom of Information
and Protection of Privacy Act, also contributes to
professional intimacy.

Question 12

Can involve psychological, spiritual, and social elements that are identified in the plan of care. Access to the client’s personal information, within the meaning of the Freedom of Information and Protection of Privacy Act, also contributes to this.

Answer 12

Professional intimacy

Question 13

The expression of understanding, validating, and resonating with the meaning that the health care experience holds for the client.

Answer 13

Empathy

Question 14

Includes appropriate emotional distance from the client to ensure objectivity and appropriate professional response.

Answer 14

Empathy

Question 15

The nurse-client relationship is one of unequal ___. Although the nurse may not
immediately perceive it, the nurse has more ___ than the client. The nurse has more authority and influence in the health care system, specialized knowledge, access to privileged information, and the ability to advocate for the client and the client’s
significant others.

Answer 15

power x2

Question 16

The appropriate use of ___, in a caring manner, enables the nurse to partner
with the client to meet the client’s needs. A misuse of ___ is considered abuse.

Answer 16

power x2

Question 17

T___ Nurse-Client Relationship includes four standard statements with indicators that describe a nurse’s accountabilities in the nurse-client relationship.

Answer 17

T-herapeutic

Question 18

The misuse of the power imbalance intrinsic in the nurse-client relationship.

Answer 18

Abuse

Question 19

It can also mean the nurse betraying the client’s trust, or violating the respect or professional intimacy inherent in the relationship, when the nurse knew, or ought to have known, the action could cause, or could be reasonably expected to cause, physical, emotional or spiritual harm to the client.

Answer 19

Abuse

Question 20

May be verbal, emotional, physical, sexual, financial or take the form of neglect.

Answer 20

Abuse

Question 21

The point at which the relationship changes from professional and therapeutic to
unprofessional and personal.

Answer 21

Boundary

Question 22

Means that the care provider is misusing the power in the relationship to meet her/his personal needs, rather than the needs of the client, or behaving in
an unprofessional manner with the client.

Answer 22

Crossing a boundary

Question 23

The misuse of power does not have to be i___ to be considered a boundary-crossing

Answer 23

i-ntentional

Question 24

May be an individual, family, group, or community.

Answer 24

Client

Question 25

In this approach, a client is viewed as a whole person.

Answer 25

Client-centred care

Question 26

Involves advocacy, empowerment and respect for the client’s autonomy, voice, self-determination and participation in decision-making. It is not merely about delivering services where the client is located.

Answer 26

Client-centred care

Question 27

Refers to the shared and learned values, beliefs, norms and ways of life of an
individual or a group. It influences thinking, decisions and actions.

Answer 27

Culture

Question 28

Involves planned and structured psychological, psychosocial and/or interpersonal interventions aimed at influencing behaviour, mood and/or the emotional reactions to different stimuli.

Answer 28

Psychotherapeutic relationship

Question 29

May include, but is not limited to, the person who a client identifies as the most important in his/her life. It could be a spouse, partner, parent, child, sibling, or friend.

Answer 29

Significant other

Question 30

There are ___ standard statements, each with accompanying indicators, which describe a nurse’s a___ in the nurse-client relationship.

Answer 30

4 / a-ccountabilities

Question 31

The i___ are not all-inclusive; rather, they’re broad statements that nurses can modify to their particular practice reality.

Answer 31

i-ndicators

Question 32

Nurses use a wide range of effective communication strategies and interpersonal skills to appropriately establish, maintain, re-establish, and terminate the nurse-client relationship.

Answer 32

1) Therapeutic communication

Question 33

The nurse meets the standard by:
a) introducing herself/himself to the client by name and discussing with the client the nurse’s and the client’s role in the therapeutic relationship (for example, explaining the role
of a primary nurse and the length of time that the nurse will be involved in the client’s care, or outlining the role of a research nurse in collecting
data)

b) addressing the client by the name and/or title that the client prefers
c) giving the client time, opportunity, and ability to explain himself/herself and listening to the client with the intent to understand and without diminishing the client’s feelings or immediately giving advice
d) informing the client that information will be shared with the healthcare team and identifying the general composition of the healthcare team
e) being aware of her/his verbal and non-verbal communication style and how clients might perceive it
f) modifying communication style, as necessary, to meet the needs of the client (for example, to accommodate a different language, literacy level, developmental stage or cognitive status)
g) helping a client to find the best possible care solution by assessing the client’s level of knowledge, and discussing the client’s beliefs and wishes
h) considering the client’s preferences when encouraging the client to advocate for his/her own behalf, or advocating on the client’s behalf
i) providing information to promote client choice and enable the client to make informed decisions
j) listening to, understanding and respecting the client’s values, opinions, needs, and ethnocultural beliefs and integrating these elements into the care plan with the client’s help

k) recognizing that all behaviour has meaning and seeking to understand the cause of a client’s unusual comment, attitude or behaviour (for example, exploring a client’s refusal to eat and
finding that it’s based in the client’s cultural/ religious observations)

l) listening to the concerns of the family and significant others and acting on those concerns when appropriate and consistent with the client’s wishes
m) refraining from self-disclosure unless it meets a specific, identified therapeutic client need, rather than the nurse’s need
n) reflecting on interactions with a client and the healthcare team and investing time and effort to continually improve communication skills
o) discussing, throughout the relationship, ongoing plans for meeting the client’s care needs after the termination of the nurse-client relationship (for example, discharge planning with the client and/or referral to community organizations).

Answer 33

1) Therapeutic communication

Question 34

Nurses work with the client to ensure that all professional behaviours and actions meet the therapeutic needs of the client.

Answer 34

2) Client-centred care

Question 35

The nurse meets the standard by:

a) actively including the client as a partner in care because the client is the expert on his/her life and identifying the client’s goals, wishes and preferences and making them the basis of the
care plan

b) gaining an understanding of the client’s abilities, limitations and needs related to his/her health condition and the client’s needs for nursing care or services
c) discussing expectations with the client and the realistic ability to meet those expectations in the context of the client’s health and the available resources
d) negotiating with the client both the nurse’s and the client’s roles, as well as the roles of family and significant others, in achieving the goals identified in the care plan
e) recognizing that the client’s well-being is affected by the nurse’s ability to effectively establish and maintain a therapeutic relationship
f) acknowledging biases and feelings that have developed through life experiences and how these attitudes could affect the nurse-client relationship
g) reflecting on how stress can affect the nurse-client relationship and appropriately managing the cause of the stress so the therapeutic relationship isn’t affected
h) demonstrating sensitivity and respect for the client’s choices, which have grown from the client’s individual values and beliefs, including cultural and/or religious beliefs

i) acknowledging difficulty establishing a therapeutic relationship with a client, and requesting a therapeutic transfer of care when
the relationship is not evolving therapeutically (for example, when a nurse is unable to establish a trusting relationship with a client, she/he may consult with the manager to request that another nurse provide care)

j) committing to being available to the client for the duration of care within the employment boundaries and role context
k) engaging the client in evaluating the nursing care and services that the client is receiving

Answer 35

2) Client-centred care

Question 36

Nurses are responsible for effectively establishing and maintaining the limits or boundaries in the therapeutic nurse-client relationship.

Answer 36

3) Maintaining boundaries

Question 37

The nurse meets the standard by:

a) setting and maintaining the appropriate boundaries within the relationship and helping clients understand when their requests are beyond the limits of the therapeutic relationship
b) developing and following a comprehensive care plan with the client and health care team that aims to meet the client’s needs

c) ensuring that any approach or activity that could be perceived as a boundary-crossing is included in the care plan developed by the healthcare team (for example, a healthcare team in a
mental-health setting may determine that having coffee with a particular client is an appropriate strategy that all nurses will consistently use when counselling the client)

d) recognizing that there may be an increased need for vigilance in maintaining professionalism and boundaries in certain practice settings (for example, when care is provided in a client’s home,
a nurse may become involved in the family’s private life and needs to recognize when her/his behaviour is crossing the boundaries of the nurse-client relationship)

e) ensuring that she/he does not interfere with the client’s personal relationships
f) abstaining from disclosing personal information, unless it meets an articulated therapeutic need of the client (for example, disclosing a personal problem may make the client feel as if his/her problems/feelings are being diminished or that the client needs to help the nurse)

g) continually clarifying her/his role in the therapeutic relationship, especially in situations in which the client may become unclear about the boundaries and limits of the relationship (for example, when an identified part of a nurse’s role includes accompanying a client to a funeral to
provide care)

h) ensuring that co-existing relationships do not undermine the judgment and objectivity in the therapeutic nurse-client relationship (for example, a nurse providing care to a child who is
a close friend of her/his child needs to be aware of the potential effect the dual relationship has on nursing care)

i) abstaining from engaging in financial transactions unrelated to the provision of care and services with the client or the client’s family/significant other
j) consulting with colleagues and/or the manager in any situation in which it is unclear whether a behaviour may cross a boundary of the therapeutic relationship, especially circumstances that include self-disclosure or giving a gift to or accepting a gift from a client

k) ensuring that the nurse-client relationship and nursing strategies are developed for the purpose of promoting the health and well-being of the client and not to meet the needs of the nurse, especially when considering self-disclosure, giving
a gift to or accepting a gift from a client

l) documenting client-specific information in the client’s record regarding instances in which it was necessary to consult with a colleague/manager about an uncertain situation (non-client-related information, such as a letter of summary or incident report, should be documented on the appropriate confidential form)
m) considering the cultural values of the client in the context of maintaining boundaries, including situations that involve self-disclosure and gift giving

Answer 37

3) Maintaining boundaries

Question 38

CNO

Answer 38

College of Nurses Ontario

Question 39

The nurse meets the standard by:

a) abstaining from accepting individual gifts unless, in rare instances, the refusal will harm the nurse-client relationship. If the refusal could be harmful, consult with a manager and/or the College and document the consultation before accepting the gift

b) accepting a team gift or an individual gift if the refusal of which has been determined to be harmful to the therapeutic relationship, only after considering:
■ that the gift was not solicited by the nurse
■ that the client is mentally competent
■ the client’s intent and expectation in offering the gift (that is, will the client expect anything in return, or will the nurse feel a special obligation to that client over others?)
■ the appropriateness of the timing (for example, on discharge versus Valentine’s Day)
■ the potential for negative feelings on the part of other clients who may not be able to, or choose not to, give gifts
■ the monetary value and appropriateness of the gifts

c) giving gifts to clients only as a group of nurses or from an agency/corporation after determining that:
■ the client is clear that the nurse does not expect a gift in return
■ it does not change the dynamics of the therapeutic relationship
■ there is no potential for negative feelings on the part of other clients or toward other members of the health care team

Answer 39

Giving and accepting gifts

Question 40

Nurses protect the client from harm by ensuring that abuse is prevented or stopped and reported.

Answer 40

4) Protecting the client from abuse

Question 41

The nurse meets the standard by:

a) intervening and reporting, when appropriate, incidents of verbal and non-verbal behaviours that demonstrates disrespect for the client
b) intervening and reporting behaviours toward a client that may be perceived by the client and/or others to be violent, threatening or intended by the nurse to inflict physical harm
c) intervening and reporting a health care provider’s behaviours or remarks toward a client that may reasonably be perceived by the nurse and/or others to be romantic, sexually suggestive, exploitive and/or sexually abusive
d) not entering a friendship, or a romantic, sexual or other personal relationship with a client when a therapeutic relationship exists

e) ensuring that after the nurse-client relationship has been terminated and the nature of the relationship has been psychotherapeutic or for the provision of intense psychosocial counselling, the nurse:
■ must not engage in a personal friendship, romantic relationship or sexual relationship with the client or the client’s significant other for one year following the termination of the therapeutic relationship
■ may, after one year, engage in a personal friendship, romantic relationship or sexual relationship with a client (or the client’s
significant other) only after deciding that such a relationship would not have a negative impact on the well-being of the client or other clients receiving care, and considering the client’s likelihood of requiring ongoing care or readmission (if the client returns for further care at the facility, the nurse must declare to her/
his manager the nature of the relationship and decline the assignment of the client)

f) being cautious about entering into a personal relationship, such as a friendship or romantic or sexual relationship, with a former client or a former client’s significant other after the termination of a therapeutic relationship if:
■ it is determined that such a relationship would not have a negative impact on the future care of the client
■ the relationship is not based on the trust and professional intimacy that was developed during the nurse-client relationship
■ the client is clear that the relationship is no longer therapeutic

g) not engaging in behaviours toward a client that may be perceived by the client and/or others to be violent, threatening or intending to inflict physical harm
h) not engaging in behaviours with a client or making remarks that may reasonably be perceived by other nurses and/or others to be romantic, sexually suggestive, exploitive and/or sexually abusive (for example, spending extra time together outside of the client’s care plan)
i) not exhibiting physical, verbal and non-verbal behaviours toward a client that demonstrate disrespect for the client and/or are perceived by the client and/or others as abusive
j) not neglecting a client by failing to meet or withholding his/her basic assessed needs

k) not engaging in activities that could result in monetary, personal, or other material benefits, gain, or profit for the nurse (other than the appropriate remuneration for nursing care or services), the nurse’s family and/or the nurse’s friends, or result
in monetary or personal loss for the client

l) not accepting the position of power of attorney for personal care or property for anyone who is or has been a client, with the exception of those clients who are direct family members of the nurse. Should a person for whom the nurse has been named power of attorney become a client, the nurse must declare to the manager that she/he is the client’s power of attorney and decline the client assignment.

Answer 41

Protecting the client from abuse

Question 42

Tool used to work through a personal situation to determine whether a particular activity or behaviour is appropriate within the context of the nurse-client relationship.

Answer 42

Decision tree

Question 43

Should be used while considering all of the components of the nurse-client relationship and the behavioural expectations contained within this document. The tool may also be useful for self-reflection and peer input as part of the self-assessment process and for guiding client care discussions in your practice setting.

Answer 43

Decision tree

Question 44

Decision Tree

Answer 44

Question 45

The follow signs are warning signs of ___ a ___.
■ spending extra time with one client beyond his/her therapeutic needs
■ changing client assignments to give care to one client beyond the purpose of the primary nursing care delivery model
■ feeling other members of the team do not understand a specific client as well as you do
■ disclosing personal information to a specific client
■ dressing differently when seeing a specific client
■ frequently thinking about a client when away from work
■ feeling guarded or defensive when someone questions your interactions with a client
■ spending off-duty time with a client
■ ignoring agency policies when working with a client
■ keeping secrets with the client and apart from the healthcare team (for example, not documenting relevant discussions with the client in the health record)
■ giving a client personal contact information unless it’s required as part of the nursing role
■ a client is willing to speak only with you and refuses to speak with other nurses

Answer 45

crossing boundary

Question 46

If the nurse is unable to speak with the colleague directly or the colleague does not recognize the problem, the next step is to speak to the colleague’s supervisor. The nurse should put the concerns in w___ and include the ___, ___, ___ and
some type of client identification, such as ___ or a file number. If the situation is not resolved, further action is needed. This action should include informing the client of his/her rights and sending a letter describing the concerns to the next level or the
highest level of authority in the agency, or reporting the matter to the College.

Answer 46

writing / date / time / witnesses / initials

Question 47

If a nurse witnesses another nurse or a member of the health care team abusing a client, the nurse must take ___. College research indicates that when someone i___ in an incident of abuse, the abuse stops. After i___, a nurse must
___ any incident of unsafe practice or unethical conduct by a health care provider to the employer or other authority responsible for the health care provider.

Answer 47

action / i-ntervenes x2 / report

Question 48

When an unregulated care provider abuses a client, the nurse must i___ to protect the client and notify the employer. In all cases, the nurse must ___ the client of
his/her right to contact police and begin criminal proceedings.

Answer 48

i-ntervene / inform

Question 49

Certain legislation requires further reporting of abuse. The Regulated Health Professions Act, 1991 requires regulated health professionals to ___ the ___ abuse of a client by a regulated health professional to the appropriate ___.

Answer 49

report / sexual / college

Question 50

The Child and Family Services Act, 1990 requires reporting suspected child abuse to the ___ ___ ___.

Answer 50

Children’s Aid Society

Question 51

A ___ ___ 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 College 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
■ endeavour to have consistent caregivers and continuity of care to promote the establishment of trust and comfort
■ provide nurses with appropriate documentation forms and consultation methods to resolve ethical and boundary issues

Answer 51

quality practice

Question 52

___ and ___ abuse includes, but is not limited to:
■ sarcasm
■ retaliation or revenge
■ intimidation, including threatening gestures/ actions
■ teasing or taunting
■ insensitivity to the client’s preferences
■ swearing
■ cultural/racial slurs
■ an inappropriate tone of voice, such as one expressing impatience

Answer 52

Verbal / emotional

Question 53

\_\_\_ abuse includes, but is not limited to:
■ hitting
■ pushing 
■ slapping
■ shakin
■ using force
■ handling a client in a rough manner

Answer 53

Physical

Question 54

\_\_\_ includes, but is not limited to:
■ non-therapeutic confining or isolation
■ denying care
■ non-therapeutic denying of privileges
■ ignoring
■ withholding:
◗ clothing,
◗ food,
◗ fluid,
◗ needed aids or equipment,
◗ medication, and/or
◗ communication

Answer 54

Neglect

Question 55

___ abuse includes, but is not limited to, consensual and non-consensual:
■ sexually demeaning, seductive, suggestive, exploitative, derogatory or humiliating behaviour, comments or language toward a client
■ touching of a sexual nature or touching that may be perceived by the client or others to be sexual
■ sexual intercourse or other forms of sexual contact with a client
■ sexual relationships with a client’s significant other
■ non-physical sexual activity such as viewing pornographic websites with a client

Answer 55

Sexual

Question 56

___ abuse includes, but is not limited to:
■ borrowing money or property from a client
■ soliciting gifts from a client
■ withholding finances through trickery or theft
■ using influence, pressure, or coercion to obtain the client’s money or property
■ having financial trusteeship, power of attorney, or guardianship
■ abusing a client’s bank accounts and credit cards
■ assisting with the financial affairs of a client without the health care team’s knowledge

Answer 56

Financial

Question 57

Not disclosing information about a client to other family members
and/or friends without the client’s consent, even after the nurse-client relationship has ended.

Answer 57

Confidentiality

Question 58

Introducing yourself to the client by your full name and as an RPN, RN, or NP and explaining your role.

Answer 58

Development

Question 59

Regularly reflecting on your relationship with the client and clarifying the roles and expectations.

Answer 59

Maintenance

Question 60

Meeting the client’s needs by helping him or her transition from your care.

Answer 60

Termination