Guidelines for Therapeutic Relationships

The nursing profession involves many frameworks that are relevant to how a nurse carries out their practice along with other health practitioners. Professionalism and therapeutic relationships are key words within nursing and these will be defined along with the key concepts that encompass them. Nursing is an art as well as a science and there are many acts, standards and guidelines that must be adhered to while carrying out this profession. These acts are defined and key principles are discussed.   The scenario of Mr S will be taken into consideration and interlinked to the competencies of nursing. Throughout this document professionalism is considered as it plays a vital role in the nursing profession.

Professionalism can be defined as demonstrating the standards that are required in practice such as professional, legal, cultural safety and ethical standards. This includes been able to display the relevant knowledge and skills required for the profession [New Zealand Nursing Council, 2012a]. The way a person acts, looks, behaves and communicates are also considered when it comes to professionalism as these play an important part in building and maintaining health consumers trust, as well as image of the nursing profession (Stein-Parbury, 2013). Professionalism can also include maintaining professional boundaries and developing appropriate relationships (NCNZ, 2012c). 

A particular relationship that is relevant in nursing is the therapeutic relationship. This type of relationship can be defined as where a professional such as a nurse and a health consumer interact with each other in a primary care setting and work together to achieve goals that are related to the clients health and course of treatment. This relationship is of a professional nature that has boundaries and a purpose. It involves concepts of caring, empathy, respect, trust, and working in an ethical manner (Arnold & Boggs, 2016). The New Zealand Nurses Organisation (NZNO) has developed a code of ethics [NZNO, 2019a], in which the main principles to be upheld while working within a therapeutic relationship include the following; fidelity, veracity, autonomy, confidentiality, beneficence, justice, non-maleficence, demonstrating professionalism and to look after the environment and its resources (NZNO, 2019a). These principles should guide a professional in their practice when working with a health consumer as they help to ensure that a professional therapeutic relationship is maintained where the client is kept safe, the client’s well-being is increased and it develops professional growth for the nurse (NZNO, 2019a). 

Throughout nursing there are many guidelines and acts that must be adhered to while practising. The first one to focus on is the competencies for registered nurses from the nursing council of new Zealand [NCNZ, 2012b]. The purpose of the nursing council of new Zealand competencies for registered nurses (NCNZ, 2012b) is to help ensure that registered nurses are competent in their ability to practice as a registered nurse. This document outlines the main competencies that a registered nurse is expected to demonstrate within their scope of practice. A registered nurse works within their scope of practice and this can involve how they are required to manage someone’s health through use of their nursing knowledge and judgement (NCNZ, 2012b). This enables them to support and advise people in relation to their heath needs and develop a plan of care. Registered nurses practice autonomously but also can work in partnership alongside many others such as health professionals, families and communities. Registered nurses are responsible for their own practice to ensure they are competent to work within their scope of practice and ensuring they are complying with legislative standards. The domains of competencies that are key elements include professional responsibility, management of nursing care, interpersonal relationships and interprofessional health care and quality improvement  (NCNZ, 2012b).

The next relevant act is the Health Practitioners Competence Assurance Act 2012 [HPCAA, 2003]. The purpose of the HPCAA (2003), is to make sure that those practicing within the health field are fit to practice and are competent. This helps ensure those within society who are accessing healthcare, that their health and safety is protected. For those working within a health profession, this act helps to monitor that they are registered with the appropriate authority that is relevant to their profession and an annual practising certificate is held which deems them competent and qualified. This act helps to regulate registered health professionals to practice within their scope of practice (HPCAA, 2003).

Under the HPCAA (2003), the authority that is responsible for practicing nurses is the nursing council. This authority is mainly concerned with health consumers safety and health practitioners are competent to practice. The nursing council has defined a code of conduct which includes appropriate standards that practicing nurses are expected to adhere to (NCNZ, 2012a). The purpose of the code of conduct (NCNZ, 2012a), for nurses is to demonstrate behaviours that are in line with the nursing profession and is the predominant document that outlines professional conduct. Due to the type of profession nursing is, nurses are expected to uphold the trust of health consumers and by not adhering to this code of conduct, it may result in disciplinary action. The code of conduct for nurses underlines eight main principles that help outline expected behaviour. The core values that feature within these eight principles include the following; integrity, partnership, respect and trust (NCNZ, 2012a). 

Under the nursing council of new Zealand, they have established a set of guidelines for social media and electronic communication (NCNZ, 2012d). The purpose of these guidelines are to ensure that nurses are maintaining professionalism and professional boundaries while using electronic media. Electronic communication and social media can be described as any technologies that enable people to interact, communicate and share information. Types of sites that could be relevant to this include Facebook, Twitter, Instagram, blogs, email and also texting through use of mobile phone. These guidelines help nurses distinguish between what is appropriate and what may potentially be harmful to their own image as well as those within their network (NCNZ, 2012d).  These guidelines incorporate the main principles which underpin the code of conduct for nurses (NCNZ, 2012a). Breaching these guidelines can involve examples of disclosing confidential information, breaching privacy of a health consumer, disabling public trust in the nursing profession, not acting with integrity and not acting respectfully towards colleagues as well as the employer (NCNZ, 2012d).

In relation to Mr S scenario and bed bathing as a student nurse, it is important to work within the correct scope of practice and ensuring that professionalism is upheld at all times (NCNZ, 2012a).  In relation to competency 1.1 (NCNZ, 2012b), it would be the student nurses responsibly to ensure that practice is competent and is carried out within an ethical, professional manner. This could be demonstrated in Mr S scenario through identifying who you are, why you are there, obtaining consent and ensuring the communication is adapted to ensure patient understanding. Correct hand hygiene and infection control processes would be carried out throughout the practice (NCNZ, 2012b). Assessment of Mr S condition would be done to see what he can carry out himself and what he may need assistance with. This can be done through communication and discussion with Mr S in order to promote independence (Arnold, & Boggs, 2016).  While carrying out this task, Mr S rights would be taken into consideration such as ensuring his privacy for example pulling the curtain so no one can see, making sure the correct assistance and equipment is utilised to prevent any risks to Mr S and that his needs are met with the upmost importance all of which is relevant to competency 1.4 (NCNZ, 2012b). 

In regards to competency 2.1 (NCNZ, 2012b), it would be ensured that Mr S is bed bathed in a safe manner for example making sure the temperature of the water is not too cold nor too hot. Explaining and communicating on what is happening throughout the process can keep Mr S informed and involved by providing the support to actively involve Mr S. Asking questions such as if he would like his own toiletries to be used, whether he would like a family member involved or not can help support the rights of Mr S and enable him to make informed decisions (Arnold & Boggs, 2016). Competency 3.1 (NCNZ, 2012b), underpins the therapeutic relationship by demonstrating empathy, respect and trust with the health consumer. Patient centred communication is relevant to developing the therapeutic relationship and in relation to Mr S, been honest, consistent and open may help develop trust. Expectations of duration and goals should clearly be outlined beforehand and warm, caring behaviours displayed throughout the therapeutic relationship. Conclusion of the therapeutic relationship should be made clear and be no surprise to Mr S as this would have been communicated earlier on (Arnold & Boggs 2016).

As discussed previously, a therapeutic relationship is where the nurse and health consumer work together to achieve the health consumers health and treatment in which there is a purpose and professional boundaries (Arnold & Boggs, 2016). If professional boundaries are violated this can result in a more social relationship and it is up to the professional nurse to maintain a professional therapeutic relationship. Some professional boundaries that can be violated and make the relationship more social, include socialising with a client once the professional relationship has terminated, over involvement of care for a specific client, sexual encounters with a client and disclosing personal information. To help maintain a therapeutic relationship which is professional, the nurse needs to ensure that they are aware of professional boundaries and their behaviour through self-awareness and self-reflection (Arnold & Boggs, 2016). 

A therapeutic relationship develops through a series of over lapping events known as pre-interaction, orientation, working phase and termination (Arnold & Boggs, 2016).  The pre-interaction phase occurs without the health consumers participation, in this case related to the scenario of Mr S who has had a stroke, as it is more centred on the nurses own self-awareness of their feelings about dealing with this patient beforehand. This allows the nurse to critically think about what issues may occur within this particular context and how they are going to carry out their practice to ensure the health consumer, Mr S, is been treated safely, fairly and without discrimination (Arnold & Boggs, 2016).

The orientation phase involves active participation from both the nurse and the health consumer, in this case, Mr S. This phase involves the initial introductions and understanding of each other’s role and development of trust and building rapport. This phase is where purpose, goals and boundaries are set and acting within a professional manner while displaying empathy can demonstrate that the health consumers health needs are important  (Arnold & Boggs, 2016). In this case Mr S may have potential feelings of vulnerability and loss of independence, which needs to be recognised and reassured by the nurses behaviour to maintain Mr S rights to independence, safety and his autonomy in health care decisions (Arnold & Boggs, 2016).

The working phase is where the goals are put into practice and issues are identified with realistic solutions that promotes the health consumers wellbeing and self-management. In the case for Mr S, this may include discussing what he can do by himself and what he may need potentially assistance with, while keeping in mind as the nurse to help promote independence for Mr S (Arnold & Boggs, 2016). The final phase is the termination phase, where the therapeutic relationship will come to an end and this would have been clearly outlined to the health consumer throughout the process so they know what and when to expect this. This phase usually involves the summary of the treatment provided and what has been achieved in relation to the goals that were made initially in the orientation phase. In Mr S scenario this would be demonstrated as concluding the bed bath and thanking Mr S. It would be made clear that the bed bath has finished and asked if there is anything he may need before you go (Arnold & Boggs, 2016).

These phases also can interlink with the AIDET model where the client is acknowledged, professional introduces themselves along with correctly identifying the client, informing the client of the duration and an explanation on what is happening and lastly thanking the client to validate the interaction has come to an end (Kaihe-Wetting, 2012). Professional boundaries would be upheld throughout these phases while dealing with Mr S by ensuring the eight principles of the code of conduct are maintained. These include that Mr S is treated with respect in relation to his dignity, privacy, cultural needs and that a level of trust was maintained while working in partnership with the nurse (NCNZ, 2012a). Examples of these principles could include the nurse demonstrating empathy, reflective listening, ensuring consent is obtained, his privacy is not breached through use of social media, asking Mr S questions to gain an understanding of what he wants in regards to his health care treatment and ensuring he is involved in decisions and participation (Arnold & Boggs, 2016).

In relation to the proposed scenario of the peer request to video the practice within a stimulated environment to send to her mother, this would undermine the nursing council of new Zealand guidelines on social media and electronic communication (NCNZ, 2012d). One of the core principles is respecting confidentiality and privacy of the health consumer (NCNZ, 2012d). Nurses have responsibility to act in an ethical and legal way in regards to the health consumers confidentiality and privacy. Any personal information needing to be obtained, must be consented and approved by the health consumer (NZNO, 2019b). According to the code of health and disability’s services consumers rights (Health and Disability Commissioner, 2012),  health consumers have the right to have their privacy respected and if this is breached they have the right to make a complaint. Although this video may be only sent to one recipient intentionally, the nurse  may unintendedly still breach the health consumers privacy and confidentiality as the nurse may not understand that once sent, it may be viewed by others or continued to be shared (NCNZ, 2012d).

To conclude, there is many considerations to reflect on throughout nursing practice. On review of the frameworks relevant to nursing, it is important to adhere to these relevant standards and frameworks to ensure the health consumer’s safety and well-being is taken care of within a professional manner. As discussed awareness of professional boundaries can help minimize potential risks of developing a social relationship and help promote a therapeutic relationship instead.  Professionalism was defined and demonstrates the importance of displaying professional behaviour in order to uphold the image of the nursing profession as well as protecting those who access healthcare.

References

• Arnold, E.C., & Boggs, K.U. (2016). Interpersonal relationships (7th ed.). Missouri, USA: Elsevier.
• Health and Disability Commissioner. (2012). Code of health and disability services: Consumers rights. Retrieved from https://www.hdc.org.nz/media/1241/code-of-rights-july-2012.pdf
• Kaihe-Wetting, I. (2012). Understanding AI2DET. Retreieved from https://teamcounties.wordpress.com/2012/07/11/understanding-ai2det/
• New Zealand Legislation. (2003). Health Practitioners Competence Assurance Act. Retrieved from http://www.legislation.govt.nz/act/public/2003/0048/latest
  /096be8ed818b56e2.pdf
• New Zealand Nurses Organization. (2019a). Guideline: Code of Ethics. Retrieved from https://www.nzno.org.nz/LinkClick.aspx?fileticket=lYmFER3ISIM%3d&portalid=0
• New Zealand Nurses Organisation. (2019b). Social media and the nursing profession: A guide to maintain online professionalism for nurses and nursing students. Wellington: New Zealand Nurses Organisation.
• Nursing Council of New Zealand. (2012a). Code of conduct for nurses. Retrieved from https://www.nursingcouncil.org.nz/Public/Nursing/Standards_and_guidelines/NCNZ/nursing-section/Standards_and_guidelines_for_nurses.aspx?hkey=9fc06ae7-a853-4d10-b5fe-992cd44ba3de
• Nursing Council of New Zealand. (2012b). Competencies for registered nurses. Retrieved fromhttps://www.nursingcouncil.org.nz/Public/Nursing/Continuing
  _competence/NCNZ/nursing-section/Continuing_Competence.aspx?hkey
  =6542ac27-9b56-4e89-b7ae-db445c5cb952
• Nursing Council of New Zealand. (2012c). Guidelines: professional boundaries. Retrieved from https://www.nursingcouncil.org.nz/Public/Nursing
  /Standards_and_guidelines/NCNZ/nursing-section/Standards_and_guidelines_for_nurses.aspx?hkey=9fc06ae7-a853-4d10-b5fe-992cd44ba3de
• Nursing Council of New Zealand. (2012d). Guidelines: social media and electronic communication .Retrieved from https://www.nursingcouncil.org.nz/Public
  /Nursing/Standards_and_guidelines/NCNZ/nursing-section/Standards_and
  _guidelines_for_nurses.aspx?hkey=9fc06ae7-a853-4d10-b5fe-992cd44ba3de
• Stein-Parbury, J. (2013). Communication. In J. Crisp., C. Taylor., C. Douglas., & G. Rebeiro, Potter and perry’s fundamentals of nursing (4th ed., pp. 204). Australia: Elsevier.