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Section A: 

Using this case study as context and using relevant scholarly references to support your discussion

What are the components of a therapeutic, person-centred relationship?

What are the benefits of forming a therapeutic, person-centred relationship with this client?

Section B: 

Using this case study as context and using relevant scholarly references to support your discussion, how does the Code of Conduct for Nurses and the Registered Nurse Standards for Practice from the NMBA, influence the formation of the therapeutic relationship in this case study?

Section C: 

Using relevant scholarly references to support your discussion, explain the concepts of paternalism and cultural safety and apply these principles to the case study.  

Components of a Therapeutic Person-Centered Relationship

A therapeutic relationship between a patient and a healthcare provider is defined as a nurturing, caring and supportive relationship that is based on mutual respect, understanding and trust (Pullen & Mathias, 2010). These relationships are usually formed during stressful periods for the patient and they can last from a brief encounter to an extended period of time depending on the severity of the patient’s condition. The basis of therapeutic relationships is to facilitate effective communication with healthcare providers and create an environment for positive interactions (Kornhaber, Walsh, Duff & Walker, 2016).

Patient-centered or person-centered care refers to how healthcare delivery and decision-making is centered on the individual patient’s needs. The goal of this type of care is to give patients the power to become active participants in matters related to their health (Reynolds, 2009). Both therapeutic relationships and person-centered care are interrelated because healthcare providers need to address the emotional concerns and needs of their patients to provide effective care (Kornhaber et al. 2016).

According to the College of Nurses of Ontario (2018), there are five components which make up the nurse-patient relationship which is similar to a therapeutic patient-focused relationship. These components are always present regardless of the length of interaction, the setting in which care is being given and whether the nurse is the main caregiver. One of these components is trust which is very important because the patient who is ill is in a vulnerable and stressful situation. Trust is important in a therapeutic relationship because it forms the basis of effective communication between the patient and the nurse (College of Nurses of Ontario, 2018, p.3).

The second component of a therapeutic relationship is professional intimacy which refers to the type of services and activities that nurses provide during care. Some of these activities include bed baths, assisting with dressing, changing continence products and assisting with toileting (College of Nurses of Ontario, 2018). These activities provide a form of closeness between the nurse and the patient and they can also involve the psychological, emotional, mental and social needs of the patient. The patient’s personal health information also forms professional intimacy because of the Protection of Privacy Act which all care providers are meant to follow (2018, p.3).

Respect is also a component of therapeutic relationships where healthcare providers are required to recognize that each individual patient is unique and should be treated with respect regardless of their economic status, cultural background, personal attributes and their illness (2018, p.3). Empathy is another component and it refers to offering validation, expressing understanding and resonating with the patient during their healthcare experience. Nurses and other care providers need to have an appropriate emotional distance with their patients so that they can remain professional and objective (2018, p.4).

Benefits of Forming a Therapeutic Person-Centered Relationship

Power in therapeutic relationships refers to how nurses have more power than their patients despite the fact they don’t perceive it. This is because nurses have more influence than their client’s within the healthcare system in the form of patient advocacy, specialized knowledge and skills and access to confidential health information (College of Nurses of Ontario, 2018). When nurses use this power in the right way, they are able to partner with their patients to achieve better health outcomes and also provide care in a respectful and dignified way. In the event this power is misused, it is then considered to be abuse of power (College of Nurses of Ontario, 2018, p.4).

Establishing a therapeutic relationship with patients is important because of the benefits that can be gained from such interactions. One benefit is that the patient’s gain understanding from nurses, instilling a feeling of importance in the patient. When a nurse understands their patient, they are able to assist them better, thereby promoting individualized care and also improving their health outcomes (Dziopa & Ahern, 2009). Individualized care is achieved by getting to know the patient better and this is done by looking at patients as individuals who have lives beyond their current illness. Individualizing a patient makes them feel important, understood and valued (2009, p.2).

Person-centered therapeutic relationships are beneficial to patients because they improve communication between the person receiving care and the healthcare team. Communication is important because it fosters partnership and collaboration in the decision making process. Patients are able to use the advice of doctors or nurses who in turn consider the needs of the patient when they initiate treatment and care plans (Sherko, Sotiri & Lika, 2013, p.461). Being informed is an important component of patient-focused relationships and it is beneficial because patients who are informed are satisfied with the care they are receiving and it reduces the occurrence of medical errors, quality issues or patient complaints (Clancy, 2008).

Establishing a therapeutic relationship with patients is also important because it determines treatment and health outcomes as well as how satisfied they are with their care (Rickert, 2012). In the case study, it would have been important for the nurse to establish a therapeutic relationship with the patient to avoid the complaint that was made against him by her and her family. If Michael, the nurse, had established good communication with the patient, gained her consent to perform the examination and asked if she was comfortable with him performing the examination, then she would have had the opportunity to address her reservations and request for a female nurse to perform the procedure. The patient felt she had no choice because Michael did not take the time to understand her personal wishes and cultural considerations with him performing the procedure. While explaining the reason for performing the examination, he should have involved her in a discussion to find her understanding of vaginal examinations, if she has ever had one before and who performed it for her (whether it was a male or female nurse).

NMBA Code of Conduct on the Formation of Therapeutic Relationships

In the case study, the patient who is Aboriginal is uncomfortable with a male nurse performing a vaginal examination because the nurse did not gain consent from the patient to perform the procedure and he was also not being culturally sensitive or respectful to her needs. According to the NMBA (2016), registered nurses work in therapeutic relationships that are focused on the patient’s wellbeing and also recognize their cultural background. Therapeutic relationships form part of the standards of practice for which all nurses under NMBA are required to follow (NMBA, 2016).

Under the therapeutic relationship practice standard, all registered nurses should respect the dignity, cultural beliefs and rights of their patients and communicate in an effective way. They should also create an environment that is safe and provide support especially in decisions that are related to their client’s health (NMBA, 2016, p.3). The nurse did not follow the practice standard of forming therapeutic relationships because he failed to take into account his patient’s cultural beliefs and rights when he performed the examination without asking if she was comfortable with it.

There exist some differences in the definition and perception of health, diseases, wellbeing and death between the dominant Australian society and Aborigines. These differences affect how they perceive western medicine and how they interact with healthcare professionals (Shahid, Finn, Bessarab & Thompson, 2009). Maher (1999), notes that some difficulties arise when healthcare professionals and Aboriginal patients interact. This is because their healthcare experience might be different than what the clinician perceives based on their cultural upbringing and belief system. It therefore becomes important to acknowledge the patient’s viewpoint on their cultures belief system so as to avoid negative interactions.

In any health related situation, Aboriginal patients need to be provided with clear explanations about their condition, what causes it and how it can be treated while at the same time respecting their cultures view of the illness.  Having an open discussion about treatment with the patient and their family is also important because it will incorporate their opinions and wishes about how best to treat them (Maher, 1999). Michael should have involved his patient in a discussion on what her cultural beliefs are regarding vaginal examinations. He should have asked what the cultural considerations are for performing these types of procedures in her community as a way of forming a therapeutic relationship.

According to the NMBA (2010), a nurse forms a therapeutic relationship with the patient by using their personal information to make nursing decisions that will have an impact on their health outcome. Nurses are entrusted to act in the best interests of their patients and this involves forming a therapeutic relationship that creates a means to assess their needs (2010, p.1). The nurse in question failed to follow this standard because he failed to involve his patient in the discussion before the examination and he did not form a therapeutic relationship which would have allowed the patient to voice her concerns.

Michael did not exercise professional boundaries which all nurses under NMBA are required to observe as they deal with patients. Professional boundaries which are essential in therapeutic relationships are the limits that protect the nurse’s authority and the vulnerability of the patient during the whole healthcare experience (NMBA, 2010). All nurses have a responsibility to maintain a relationship with their patients that is based on therapeutic goals and health outcomes. It is their responsibility to maintain professional boundaries and make sure they do not cross them because this is seen to be a misuse of power (Kornhaber et al., 2016). What Michael did is unprofessional and he crossed a boundary because he failed to consult his patient if she wanted him to do the examination.

Paternalism refers to when a person interferes with another’s wishes, interests or actions in-order to avoid harm or any benefit to the individual. If an act is carried out intentionally or it is omitted, it is referred to as paternalism because it is done against a person’s consent regardless of whether the purpose was to do good (Cody, 2003, p.288). In nursing, it occurs when a nurse assumes that they are making the right decision for their patient. Many healthcare professionals have been known to act in a paternalistic way because decisions are made without consulting the patient (Gates & Fink, 2008, p.625). Clinicians believe that they know what is best for the patient and they therefore don’t need to consult with them (Yeo, Moorhouse, Khan & Rodney, 2010).

Paternalism is a widespread practice in many healthcare facilities around the world. However, there are certain groups of people who are likely to be treated in a paternalistic way more than others (Cody, 2003). People who are unable to make decisions autonomously and also those that need more assistance are likely to experience paternalistic behavior. Cody (2003) highlights the fact that people who are poor, disenfranchised, lack power and are from minority groups like the Aboriginals face a higher likelihood of receiving paternalistic treatment from healthcare providers (2003, p.291). There is a clear case of paternalism in the case study because the nurse made the assumption that the type of care he was giving was safe and respectful to the client. He also did not involve her in the decision-making process and assumed his actions were for the best. What he did is a good example of paternalism where the provider believes that their actions are for the good of the patient and they therefore don’t involve the patient’s wishes or consent.

Cultural safety is a concept that was created by Irihapeti Ramsden in Aotearoa, New Zealand after a Maori student in her first year of nursing asked about cultural safety (Funnell, Koutoukidis & Lawrence, 2009, p.102). This was during a time when the Maori faced negative health statistics and had become marginalized from mainstream health services dominated by the Europeans. Ramsden together with the Nursing Council of New Zealand in 1996 incorporated cultural safety into the nursing curriculum and defined cultural safety as providing effective nursing to individuals and their families who are from a different cultural backgrounds by healthcare providers who have gone through a reflection of their own cultural identity and recognize the impact of their cultural backgrounds on how they practice nursing (Ramsden, 2002).

The focus of cultural safety according to Ramsden (2002) was on improving the health and wellbeing of Indigenous New Zealanders, improving the delivery of healthcare to these communities by having a culturally safe healthcare team, recognizing that inequalities existed within the healthcare system and challenging healthcare workers to balance power in their relationships with patients so that they received proper service. Ramsden (2002, p.121) in her research noted that cultural safety was about power in relationships and setting up systems which allowed the least powerful like marginalized communities to monitor the services of the people who had power.

The consumers would also have the power to comment about the nursing services they receive and participate in improving health outcomes (Nursing Council of New Zealand, 2011). In the case study, cultural safety was not observed because the nurse did not acknowledge the cultural background of his patient and he did not relate to her needs of whether she felt comfortable before and during the procedure. He failed to balance power in the relationship with the patient which led to ineffective and inequitable care because his patient felt alienated and without an alternative choice.

Conclusion:

The essay focused on therapeutic relationships by examining the interaction of a male nurse with his female patient during a vaginal exam. Therapeutic relationships are formed by having trust, respect and understanding between the care provider and the patient. In the case study, these aspects were not present which resulted in the patient making a complaint against the nurse. The paper also looked at the benefits of a therapeutic relationship that focused on the patient and it determined that if there is proper communication and understanding between both parties then better health outcomes can be achieved.

By looking at the NMBA Code of Conduct, standards of practice for therapeutic relationships, paternalism and cultural safety it was determined that nurses are should consider the cultural background and beliefs of their patients before, during and after healthcare delivery to reduce incidences of complaints such as the one that was identified in the case study.

References:

Clancy, C.M. (2008). How patient-centered healthcare can improve quality. Retrieved 9 August, 2018, from https://www.psqh.com/marapr08/ahrq.html

Cody, W.K. (2003). Paternalism in nursing and healthcare: central issues and their relation to theory. Nursing Science Quarterly, 16(4), 288-296. Retrieved 9 August, 2018, from https://scholar.google.com/scholar_url?url=http%3A%2F%2Fbioetyka.uw.edu.pl%2Fwp-content%2Fuploads%2F2014%2F10%2FCody.pdf&hl=en&sa=T&oi=gga&ct=gga&cd=1&d=14684312762309493975&ei=oulqW82FF4SQmwGl_ryoDg&scisig=AAGBfm37uEs_KWrtZ3di7y3-cluibVleZg&nossl=1&ws=1366x620

College of Nurses of Ontario (2018). Therapeutic nurse-client relationship, revised 2006. Retrieved 9 August, 2018, from https://www.cno.org/globalassets/docs/prac/41033_therapeutic.pdf

Dziopa, F., & Ahern, K. (2009). What makes a quality therapeutic relationship in psychiatric/mental health nursing: a review of the research literature. The Internet Journal of Advanced Nursing Practice, 10(1), 1-9. Retrieved 8 August, 2018, from https://espace.library.uq.edu.au/data/UQ_177415/UQ177415_OA.pdf?Expires=1533797245&Signature=CeoLOf6AnAYb4rm5LkEyA5K1PbcSUoe8d-Ww-hiUwYO7NlEKxoTPyIUtIg1vzIuQp8KrC0K2CVmUP8KGROrlzxHqiPYuW67hwB2j3OoyYHsqyigfR7zPQGgjk1lpQMUhVULqryT7m3BnJTRNcJg3jufCwdTlHz76h2f1vQW0NF6pcARhiSsH3iwk16tpBV34Sj5YnqsZm5pleBqOkUXGGZEqn5ns177eQVxySn3b1PwWNI4hgrN2KikZedjPXbnycN9hpd8ba-vdSs51ct610URAk3z1~qld9ePhVRYBIZZgDJkgUJdvmKyaQOdSgu5N4wtGp9fKG5EsA~EPrw~TaA__&Key-Pair-Id=APKAJKNBJ4MJBJNC6NLQ

Funnell, R., Koutoukidis, G., & Lawrence, K. (2009). Tabbner’s nursing care:  theory and practice. Chatswood, NSW: Elsevier Australia

Gates, R.A., & Fink, R.M. (2008). Oncology nursing secrets. St. Louis, Missouri: Mosby Elsevier

Kornhaber, R., Walsh, K., Duff, J., & Walker, K. (2016). Enhancing adult therapeutic interpersonal relationships in the acute health care setting: an integrative review. Journal of Multidisciplinary Healthcare, 9, 537-546. Retrieved 8 August, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5072574/

Pullen, R., & Mathias, T. (2010). Fostering therapeutic nurse-patient relationships. Nursing Made Incredibly Easy, 8(3). Retrieved 8 August, 2018, from https://journals.lww.com/nursingmadeincrediblyeasy/fulltext/2010/05000/Fostering_therapeutic_nurse_patient_relationships.1.aspx

Maher, P. (1999). A review of ‘traditional’ aboriginal health beliefs. Australian Journal of Rural Health, 7(4), 229-236. Retrieved 9 August, 2018, from https://onlinelibrary.wiley.com/doi/full/10.1046/j.1440-1584.1999.00264.x

NMBA (2016). Registered nurse standards for practice. Retrieved 9 August, 2018, from https://www.nursingmidwiferyboard.gov.au/documents/default.aspx?record=WD16%2F19524&dbid=AP&chksum=R5Pkrn8yVpb9bJvtpTRe8w%3D%3D

NMBA(2010). A nurse’s guide to professional boundaries. Retrieved 9 August, 2018, from https://www.nursingmidwiferyboard.gov.au/documents/default.aspx?record=WD10%2F1347&dbid=AP&chksum=bes7sYtZAWnmggO%2FzV0uBQ%3D%3D

Nursing Council of New Zealand (2011). Guidelines for cultural safety, the Treaty of Waitangi and Maori health in nursing education and practice. Retrieved 9 August, 2018, from https://pro.healthmentoronline.com/assets/Uploads/refract/pdf/Nursing_Council_cultural-safety11.pdf

Ramsden, I. (2002). Cultural safety and nursing education in Aotearoa and Te Waipounamu (Doctoral dissertation, Victoria University, Wellington, New Zealand). Retrieved 9 August, 2018, from https://croakey.org/wp-content/uploads/2017/08/RAMSDEN-I-Cultural-Safety_Full.pdf

Reynolds, A. (2009). Patient-centered care. Radiologic Technology, 81(2), 133-147. Retrieved 9 August, 2018, from https://www.radiologictechnology.org/content/81/2/133.short

Rickert, J. (2012). Patient-centered care: what it means and how to get there. Retrieved 9 August, 2018, from https://ahpo.net/assets/patient-centered-care-what-it-means-and-how-to-get-there-blog2.pdf

Shahid, S., Finn, L., Bessarab, D., & Thompson, S.C. (2009). Understanding, beliefs and perspectives of Aboriginal people in Western Australia about cancer and its impact on access to cancer services. BMC Health Services Research, 9, 132. Retrieved 9 August, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2731745/

Sherko, E., Sotiri, E., & Lika, E. (2013). Therapeutic communication. JAHR, 4(7), 457-466. Retrieved 9 August, 2018, from https://hrcak.srce.hr/file/162627

Yeo, M., Moorhouse, A., Khan, P., & Rodney, P. (2010). Concepts and cases in nursing ethics. Toronto, Ontario: Broadview Press

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