Nursing knowledge

PRACTICE SUPPORT Nurse-Client Relationships

2855 Arbutus Street,Vancouver, BC V6J 3Y8Tel 604.736.7331 or1.800.565.6505www.crnbc.caCopyright CRNBC/Nov 2006Pub. No. 406

NURSE-CLIENT RELATIONSHIPSContentsIntroduction ..........................................................................................................................4The Nurse-Client Relationship................................................................................................5 ACKNOWLEDGING THE POWER IMBALANCE: CLIENT VULNERABILITY ..................................................... 6 UNDERSTANDING INTERPERSONAL RELATIONSHIPS .......................................................................................6 Personal Relationships............................................................................................................................7 Professional Relationships ......................................................................................................................7Understanding Boundaries in the Nurse-Client Relationship ..................................................9 CROSSING BOUNDARIES................................................................................................................................10 SITUATIONS THAT MAY CREATE PROBLEMS WITH BOUNDARIES ......................................................................10 Giving and Receiving Gifts .......................................................................................................................10 Monetary Gain or Personal Benefit...........................................................................................................11 Hugging or Touching................................................................................................................................12 Managing Personal and Professional Relationships (dual roles)...............................................................12 Self-disclosure ........................................................................................................................................13Applying the Practice Standard..............................................................................................14 GIVING AND RECEIVING GIFTS.........................................................................................................................14 MONETARY GAIN OR PERSONAL BENEFIT ........................................................................................................16 HUGGING OR TOUCHING ................................................................................................................................17 MANAGING PERSONAL AND PROFESSIONAL RELATIONSHIP............................................................................18 CARING FOR CLOSE FRIENDS OR FAMILY.........................................................................................................19 WORKING AND LIVING IN SMALL COMMUNITIES .............................................................................................19 SELF-DISCLOSURE..........................................................................................................................................20 ABUSE ...........................................................................................................................................................21Bibliography..........................................................................................................................22Resources for Nurses.............................................................................................................23College of Registered Nurses of British Columbia 3

NURSE-CLIENT RELATIONSHIPSIntroductionAll health professions in British Columbia are required by law to establish programs to prevent sexual misconduct.A primary duty of the Health Professions Act is “to serve and protect the public.” The Act directs health professioncolleges “to establish . . . a patient relations program to seek to prevent professional misconduct of a sexualnature.” The College of Registered Nurses of British Columbia (CRNBC) has interpreted the Act broadly toinclude a comprehensive program on nurse-client relationships to protect clients from abuse of any sort.CRNBC has fulfilled this requirement in a variety of ways, including developing the Practice Standard Nurse-Client Relationships, which sets out the requirements for nursing practice in this area. Further, CRNBC’sProfessional Standards for Registered Nurses and Nurse Practitioners and the Canadian Nurses Association’s(CNA’s) Code of Ethics for Registered Nurses set out explicit expectations about professional nurse-clientrelationships.In this document, CRNBC provides a more detailed discussion of the boundaries of the nurse-client relationshipand describes the role of nurses1 in maintaining a professional relationship with all clients. It is intended that thisresource will stimulate discussion and guide decision-making about nurse-client relationships in all practicesettings and in all domains of practice. The scenarios found in this booklet outline some of the realities andcomplexities faced by nurses in their relationships with clients.2Can you answer these questions? Can you accept a gift from a client? A student? When is it ok to hug a client? A student? A staff member? Can you date a client? A former client? A client’s family member? How should you act when you meet a client in a social setting? Can you provide nursing care to your family or friends? Paid? Unpaid? What can you tell clients about your personal life?1 Nurse refers to the following registrants: registered nurses, nurse practitioners, licensed graduate nurses and student nurses.2 Client: individuals, families, groups, populations or entire communities who require nursing expertise. In some clinical settings. the client may be referred to as a patient or resident.4 College of Registered Nurses of British Columbia

NURSE-CLIENT RELATIONSHIPSThe Nurse-Client RelationshipThe nurse-client relationship is professional and therapeutic. It ensures the client’s needs are first and foremost. Itexists to meet the needs of the client, not the needs of the nurse. It is always the nurse who is responsible forestablishing and maintaining boundaries with clients, regardless of how the patient behaves. The components ofthe nurse-client relationship are outlined in Table 1.Table 1: Components of the nurse-client relationship There are five components to the nurse-client relationship: trust, respect, professional intimacy, empathy and power. Regardless of the context, length of interaction and whether a nurse is the primary or secondary care provider, these components are always present. Trust. Trust is critical in the nurse-client relationship because the client is in a vulnerable position. Initially, trust in a relationship is fragile, so it’s especially important that a nurse keep promises to a client. If trust is breached, it becomes difficult to re-establish. Respect. Respect is 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. Professional intimacy. Professional intimacy is inherent in the type of care and services that nurses provide. It may relate to the physical activities, such as bathing, that nurses perform for, and with, the client that creates closeness. 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 also contributes to professional intimacy. Empathy. Empathy is the expression of understanding, validating and resonating with the meaning that the health care experience holds for the client. In nursing, empathy includes appropriate emotional distance from the client to ensure objectivity and an appropriate professional response. Power. The nurse-client relationship is one of unequal power. Although the nurse may not immediately perceive it, the nurse has more power 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. The appropriate use of power, in a caring manner, enables the nurse to partner with the client to meet the client’s needs. A misuse of power is considered abuse. College of Nurses of Ontario. (2006). Therapeutic nurse-client relationship. Toronto: Author.College of Registered Nurses of British Columbia 5

NURSE-CLIENT RELATIONSHIPSACKNOWLEDGING THE POWER IMBALANCE:CLIENT VULNERABILITYIn the nurse-client relationship, a power imbalance exists. It is usually the nurse who is in a position of power andthe client who is dependent and has less power. The nurse has a broad range of competencies that clients needincluding knowledge, authority, influence and access to privileged information about clients. The client has lessability to control situations and so is at a disadvantage.This power imbalance can put clients in a vulnerable position. Clients are often without defences and mightdepend on nurses to meet basic needs. Clients may perceive that their health, well-being and safety depend on thenurse. Clients might not have a network of supportive family and friends and may want to depend on the nursebeyond the practice setting. Some clients, such as those with mental health problems or those in need of ongoingcare, could be particularly vulnerable.It is the responsibility of the nurse to be aware of the power imbalance, to recognize the potential for clients to feelintimidated and to create a therapeutic relationship. This awareness is a prerequisite to taking further steps toestablish and maintain appropriate boundaries.3 It is always the nurse’s responsibility to maintain the integrity ofthe boundary with clients and their significant others. The appropriate use of power in the nurse-clientrelationship ensures the client’s needs are foremost and the client’s vulnerability is protected.UNDERSTANDING INTERPERSONAL RELATIONSHIPSInterpersonal relationships are inherent in interactions among individuals and may be personal or professional.Personal relationships can be categorized as a casual acquaintance, a platonic friendship, or a romantic or sexualrelationship. As health care professionals, nurses take on certain responsibilities and give up certain opportunities.CRNBC’s Standards of Practice (Professional Standards, Practice Standards and Scope of Practice Standards)provide direction and outline the minimum expectations for nurses in practice. All nurses in B.C. are expected tohave the necessary knowledge, skills, attitudes and judgment to provide safe, competent and ethical care.The nurse-client relationship is a professional relationship established to meet the needs of the client. Some of thedifferences between a professional and a personal relationship are listed in Table 2. This list is by no meansexhaustive; there are many other factors that also describe the differences between professional and personalrelationships.It is the nurse’s responsibility to establish and maintain a professional relationship with clients. When a nurseknows a client through a personal relationship, it may be difficult to maintain sufficient objectivity about theperson to enable the nurse to enter into a professional relationship. Caution is required. Nurses need to be directand explicit with clients, potential clients and former clients about the nature of their relationship. Difficultiesarise when there is a lack of clarity about when the relationship is personal and when it is professional. Nurses whothemselves are vulnerable because of difficult circumstances in their own life need to be particularly self-aware andthoughtful about maintaining professional boundaries in the nurse-client relationship.3 A boundary is a dynamic line of demarcation in the nurse-client relationship between professional and therapeutic, and non-professional and personal. When a nurse crosses a boundary, the nurse is behaving in an unprofessional manner and misuses the power in the relationship.6 College of Registered Nurses of British Columbia

NURSE-CLIENT RELATIONSHIPSPersonal RelationshipsCasual RelationshipsCasual relationships arise when nurses, as members of a community, are acquainted with other people in thenormal course of living. A casual relationship is not regarded by anyone as close, romantic or sexual.FriendshipsFriendships or platonic relationships may exist between a nurse and a client, a client’s significant other or both,outside of the nurse-client relationship. A friendship is a close relationship which may have an important meaningand history for everyone involved, but it is not regarded by anyone as romantic or sexual. Nurses do not enter intofriendships with clients, but they may have a pre-existing friendship with someone who becomes a client.Romantic or Sexual RelationshipsA sexual relationship implies erotic desires or activities, while a romantic relationship generally involves both anemotional and sexual intimacy. Romantic or sexual relationships with clients are unethical and unprofessional,and they have a high probability of harmful consequences to the client. Nurses do not enter into a sexual orromantic relationship with clients, although they may have a pre-existing relationship with someone who laterbecomes a client.Professional RelationshipsThe professional relationship between nurses and their clients is based on a recognition that clients (or theiralternate decision-makers) are in the best position to make decisions about their own lives when they are activeand informed participants in the decision-making process. These relationships must neither have a negative effecton meeting a client’s therapeutic needs nor in any way interfere with a client’s right to receive safe, competent andethical care.Maintaining boundaries in professional relationships can be challenging. It is the nurse’s responsibility to set theboundaries by: self-reflection; following the care plan; meeting personal needs outside the relationship; beingsensitive to context; and initiating, maintaining and terminating the nurse-client relationship appropriately.College of Registered Nurses of British Columbia 7

NURSE-CLIENT RELATIONSHIPSTable 2: Differences between Professional and Personal Relationships Professional Relationship Personal Relationship Characteristic (nurse-client) (casual, friendship, romantic, sexual) Behaviour Regulated by a code of ethics and Guided by personal values and professional standards. beliefs. Remuneration Nurse is paid to provide care to client. No payment for being in the relationship. Length of relationship Time-limited for the length of the May last a lifetime. client’s need for nursing care. Location of relationship Place defined and limited to where Place unlimited; often undefined. nursing care is provided. Purpose of relationship Goal-directed to provide care to client. Pleasure, interest-directed. Structure of Nurse provides care to client. Spontaneous, unstructured. relationship Power of balance Unequal: nurse has more power due Relatively equal. to authority, knowledge, influence and access to privileged information about client. Responsibility for Nurse (not client) responsible for Equal responsibility to establish relationship establishing and maintaining and maintain. professional relationship. Preparation for Nurse requires formal knowledge, Does not require formal knowledge, relationship preparation, orientation and training. preparation, orientation and training. Time spent in Nurse employed under contractual Personal choice for how much time relationship agreement that outlines hours of work is spent in the relationship. for contact between the nurse and client.Adapted from: British Columbia Rehabilitation Society (now known as the Vancouver Hospital & Health Sciences Centre). 1992.8 College of Registered Nurses of British Columbia

NURSE-CLIENT RELATIONSHIPSUnderstanding Boundaries in the Nurse-Client RelationshipIt is important for nurses to be aware when a professional relationship is slipping into the non-professional realmand to take immediate action. Nurses do not enter into a friendship or a romantic or sexual relationship withclients. Nurses are cautious in socializing with clients and/or former clients, especially when the client or formerclient is vulnerable and may require ongoing care. Nurses are responsible for maintaining a professional nurse-client relationship regardless of how the client behaves.Table 3 lists some “yellow lights” that may serve as a caution to nurses about their behaviour or the behaviour oftheir colleagues. Any of these behaviours may signal the need for nurses to reflect on the nature of the nurse-clientrelationship and to clarify, with a knowledgeable and trusted colleague, that the relationship is professional.Table 3: Yellow Lights: Warning Signals of Nurse Behaviour Frequently thinking of the client when away from work. Frequently planning other client’s care around the client’s needs. Seeking social contact or spending free time with the client. Sharing personal information or work concerns with the client. Feeling worried about the client’s or family’s view of the nurse as a person if their expectations are not met. Feeling so strongly about the client’s goals that colleagues’ comments or client’s/family’s wishes are disregarded. Feeling responsible for the client’s limited progress. Feeling unusual irritation if someone or something in the system creates a barrier or delay in the client’s progress. Hiding aspects of the relationship with the client from others. Having more physical touching than is appropriate or required for the situation. Introducing sexual content in conversation with the client. Feeling a sense of excitement or longing related to the client. Making special exceptions for the client because s/he is appealing, impressive or well connected. Using the client to meet personal needs for status, social support or financial gain. Receiving feedback from others that behaviour with the client is overly familiar or intrusive. Having romantic or sexual thoughts about the client.Adapted from British Columbia Rehabilitation Society (now known as the Vancouver Hospital & Health Sciences Centre). 1992.Boundaries Workshop Material.College of Registered Nurses of British Columbia 9

NURSE-CLIENT RELATIONSHIPSIn cases where a nurse’s behaviour is unprofessional, it is important to determine if the behaviour reflects apattern or is an isolated event only. If there is a pattern of inappropriate behavior or if abuse is involved, thenintervention and/or reporting are required. (See the CRNBCs Practice Standard Duty to Report, pub. no. 436).In either situation, whether an isolated event or a pattern of unprofessional behavior, there may be a need for thenurse to withdraw from the relationship. Exploring concerns about boundaries with a knowledgeable and trustedcolleague helps nurses to understand their own feelings and motives and recognize their own vulnerabilities. Suchreflection helps makes boundary issues more apparent, helps nurses understand the importance of boundaries andhelps identify strategies for establishing and maintaining boundaries.CROSSING BOUNDARIESSome behaviours are unacceptable in the nurse-client relationship and clearly violate professional standards.Unacceptable behaviours include verbal, physical, sexual, emotional and financial abuse and neglect. Abuse is abetrayal of trust or the misuse of the power imbalance between the nurse and the client. It is unacceptable fornurses to engage in behaviours, or make remarks, toward clients that are perceived to be demeaning, seductive,insulting, exploitive, disrespectful or humiliating. Taking actions that result in monetary or personal benefit to thenurse or monetary or personal loss to the client are also unacceptable. (See the discussion below on situations thatmay create problems with boundaries.)Other behaviours by the nurse toward clients, while unacceptable in most contexts, may be acceptable andappropriate in special circumstances. For example, while generally nurses should not disclose information aboutthemselves to clients, there may be times when select and limited disclosure may be judged helpful in meeting thetherapeutic needs of the client.While some boundaries are absolute and must never be violated (e.g., any form of abuse of clients), there may beshades of gray around other boundaries that require the use of good judgment and careful consideration of thecontext (e.g., when, if ever, is it appropriate to hug a client?). While each separate situation may appear harmless,when put together they may form a pattern indicating a boundary has been crossed. Inappropriate relationshipswith clients may start with something very benign then gradually progress until the nurse has clearly violated aboundary in the nurse-client relationship and failed to meet the CRNBC Standards for Registered Nursing Practicein British Columbia, and the CNA Code of Ethics for Registered Nurses. For example, having a casual andcoincidental coffee with a client’s significant other in the hospital cafeteria can become a friendship and then turninto a romantic relationship.SITUATIONS THAT MAY CREATE PROBLEMS WITH BOUNDARIESGiving and Receiving GiftsGenerally, it is not acceptable for nurses and clients to exchange gifts. A group of nurses may give or receive atoken gift in situations where it has therapeutic intent. Any significant gift must be returned or redirected.A gift is defined as anything that is voluntarily transferred from one person or group to another withoutcompensation. Gifts may be small, such as chocolates, or large, such as a bequest in a will. Gifts have many10 College of Registered Nurses of British Columbia

NURSE-CLIENT RELATIONSHIPSdifferent connotations. There may be situations when refusing a gift may be difficult and seem impolite. Giftgiving may be an expectation under certain circumstances or within some cultures. It may be an expression ofgratitude or the recognition of an event. Gifts may indicate favouritism or create a sense of obligation. A gift,intended as a simple expression of appreciation from a client to a nurse, may be perceived by colleagues as specialtreatment of that nurse which can create resentment. The nurse may perceive the gift as pressure from the client toprovide extra care. Other clients may feel under obligation to provide similar gifts. In any case, a gift has thepotential to change the nature of a relationship, depending on how it is intended and how it is perceived. Nursesneed to consider carefully the implications of giving or receiving any gift, including its value, intent andappropriateness. For the most part, nurses politely decline gifts and they work with their agencies to develop clearand relevant policies for all staff regarding gifts.There are some limited circumstances when giving or receiving a gift is acceptable. Generally, it is more acceptablefor a gift to be given to or from a group. Any gift must be openly declared to ensure transparency. Nurses may accept a token gift on behalf of others who provided care. For example, a nurse may accept a box of chocolates from a client to share with other staff. Occasionally a gift may be part of a therapeutic plan for the client. For example, the nursing team may give a small gift to hospitalized children on their birthday. Gifts from clients may be accepted through a charitable organization and used directly or indirectly to benefit client care. For example, a client who wishes to give money, even a small amount, to a nurse in appreciation of care received must be directed to the hospital’s foundation.Monetary Gain or Personal BenefitNurses have access to personal and confidential information about their clients. It is possible for nurses, who areunaware of their professional responsibilities, to take advantage of situations that could result in personal,monetary or other benefits for themselves or others. Nurses have the potential to borrow or misappropriatemoney. A nurse could also influence or coerce a client to make decisions resulting in benefit to the nurse orpersonal loss to the client. It is unacceptable for nurses to take such actions.Clients who have formed a close relationship with a particular nurse over time may wish to include the nurse intheir wills in gratitude for care and services provided. This situation is particularly difficult for several reasons.There may be family considerations. The family may or may not be supportive of the bequest. The family and thenurse may not even know about the bequest until the will is read. Family members or colleagues may perceive thatthe nurse has exerted undue influence on vulnerable clients. For these reasons nurses must not accept a bequest ofany nature. As with a gift, the best option is to refuse a bequest with a polite explanation or to reassign it to anappropriate charitable organization.For the same reasons, nurses do not act for clients through representation agreements nor do they accept power ofattorney responsibilities to make legal and financial decisions on behalf of their clients. There may occasionally bean exception to this principle when the client is also a relative or close friend and no alternative arrangement canbe made. The nurse needs to discuss the situation with both her supervisor and other family members.College of Registered Nurses of British Columbia 11

NURSE-CLIENT RELATIONSHIPSHugging or TouchingThe nature of nursing involves touching clients. Nurses use both task touch and supportive touch. Task touch isused to perform procedures or to assist clients with an activity. Supportive touch is touching the client when thereis no physical need. It is used to provide comfort or encouragement and when used effectively it has a calming andtherapeutic effect on the client. There are also formal touch therapies that have distinct techniques and therapeuticgoals.Nurses may touch or hug children, adult clients or their clients’ significant others in some situations to besupportive. While it is a therapeutic, human and caring response to a number of situations, such contact has thepotential to be misinterpreted by vulnerable clients. The type, location and amount of touch will vary with thenurse’s and the client’s age, gender and culture. Nurses need to carefully assess each situation and determine thatsupportive touch would be appropriate and welcome. They need to be aware of the client’s perception of themeaning of the touch. The perception and response of the client’s family is also important.Managing Personal and Professional Relationships (dual roles)Nurses usually have both casual and close relationships with people in their communities. A dual role exists whensomeone a nurse has a personal relationship with becomes a client and a professional relationship is established.The nurse must clarify this new professional relationship with the client in order to provide appropriate nursingcare. If unable to clarify the relationship is professional, the nurse should assign the client to another nurse andwithdraw because a dual role can be problematic, having the potential to create conflict, a loss of objectivity andharm clients.For these same reasons, when a professional nurse-client relationship exists it is unacceptable for a nurse to enterinto a friendship or engage in a romantic, dating or sexual relationship with a client or a client’s significant others.Furthermore, nurses need to be cautious about entering into personal relationships with former clients or theirsignificant others, particularly those clients who are vulnerable or who have the potential to become clients again.Caring for Close Friends or FamilyThe problems of a dual role are accentuated when close friends or family members become clients. It is rarelypossible for the nurse to maintain sufficient objectivity about the person to enable a therapeutic nurse-clientrelationship. However, at times, a nurse may have to care for a friend or family member such as in an emergency.When a nurse has no immediate option other than to care for a loved one, care is handed over to anotherappropriate care provider when it becomes possible.At times, a nurse may want to care for a friend or family member. Problems may arise when the nurse attempts tohave a professional and a personal relationship at the same time. To avoid the confusion of roles and the blurringof personal and professional boundaries, a nurse is cautious, clarifies the nature of the relationship and carefullyconsiders the impact of the dual role on the client, the client’s significant others and the nurse. Discussing the dualrole may be difficult for the client as well as the nurse. If the nurse cannot clarify that the relationship isprofessional, the nurse makes alternative care arrangements and withdraws from the nurse-client relationship.Even when the nurse does care for a friend or family member, the overall responsibility for the nursing care should12 College of Registered Nurses of British Columbia

NURSE-CLIENT RELATIONSHIPSbe assigned to another nurse who has only a professional relationship with the client. The nurse with the personalrelationship may play a supportive or secondary role.Working in Small, Rural or Remote CommunitiesThere is a natural overlap and interdependence of people living in small, rural or remote communities. In smallcommunities nurses come to know people on a personal basis. When someone from the community becomes aclient, the nurse needs to clarify the shift from a personal to a professional relationship in an open and transparentway. The nurse ensures the client’s needs are first and foremost and manages confidentiality issues appropriately.Nurses need to distinguish between “being friendly” and “being friends.” They need to set clear boundaries aboutwhen they are acting in a personal role and when they are acting in a professional role. By establishing theseboundaries nurses protect client confidentiality and they protect their own personal time.Note that small communities are not limited to rural and remote communities; they also include small or discretecommunities within large urban centres (e.g., religious, gay or military communities).Self-disclosureSelf-disclosure occurs when the nurse shares personal information with a client. Self-disclosure may be used inmoderation as long as it is focused on the needs of the client. In these situations disclosing personal informationmay have the therapeutic intent of reassuring, counselling or building rapport with clients. Disclosing personalinformation that is lengthy, self-serving or intimate is never acceptable.College of Registered Nurses of British Columbia 13

NURSE-CLIENT RELATIONSHIPSApplying the Practice StandardThe following scenarios have been prepared to foster discussion about appropriate and inappropriate behavioursof nurses in the context of the nurse-client relationship. The following questions should be considered whenthinking about each scenario: What employer policy, Standards of Practice or elements of the Code of Ethics for Registered Nurses are involved? How can the nurse use power in a caring manner? What can the nurse do to enable the client to trust the nurse? How can the nurse demonstrate respect for the client or the client’s significant other or family? Is the employer aware the nurse is performing the activity and what is the agency’s policy related to the activity? What kinds of intimate activities might the nurse be expected to perform that might create a personal and private closeness? What are the overall considerations, implications or possible consequences for the nurse? For the client? For the family? For colleagues? For the employer? What is the next appropriate behaviour on the part of the nurse?GIVING AND RECEIVING GIFTSScenario 1You are a nurse working on a pediatric floor. A five-year-old child with a chronic disease was admitted a month agoand you have become particularly attached to him. He is bright and brave, but comes from a poor family. His parentscan only visit infrequently. On his birthday you buy a $50 toy for him and make a cake. He is thrilled. You feel good.The next day another child says, “It was my birthday two days ago. Why didn’t you give me a present?” Your colleaguesappear angry and resentful.DiscussionIn your enthusiasm to do something special for a disadvantaged child, you independently singled out anindividual client. You did not carefully consider the broader implications of giving a significant gift to one child.As a result, another client felt excluded. The gift can be seen as an attempt by you to create a special, personalrelationship beyond the boundaries of the nurse-client relationship. Your colleagues may have felt resentful forseveral reasons, including having been excluded from the plan and seeing unreasonable expectations beingestablished on the unit. The reaction of the parents to their child receiving an expensive gift is not known. The giftand cake may create an element of mistrust if the parents are concerned about you putting them at a disadvantageand alienating their child’s affection. You now need to meet with your colleagues to discuss the issue. The pediatricunit would benefit from establishing a policy about celebrating all children’s birthdays. Such a policy mightinclude using a fund to buy small presents for children on behalf of all staff and ordering a cake from the kitchen,which would be shared by staff and children alike. You will also need to discuss the gift with the child’s parents,noting your good intent, but acknowledging you overstepped the boundaries of the nurse-client relationship.14 College of Registered Nurses of British Columbia

NURSE-CLIENT RELATIONSHIPSScenario 2You have been caring for an elderly couple at home periodically for many years. Often they serve you a cup of tea and acookie before you go to your next client. You consider it your coffee break and it gives the couple some much neededsocial contact. One day the woman gives you the tea cup and saucer to take home. She says, “Because it is yours. Youalways use it. We are giving away things we can’t take to the nursing home.” When you mention the incident to acolleague she says, “You should never have taken it. They might later accuse you of theft. In fact, you shouldn’t evenaccept a cup of tea.”DiscussionAccepting a cup of tea and taking time to socialize with this couple can be considered part of the therapeutic planbut you should not consider it your coffee break as that would be blurring your personal and professional roles.You should confirm each time that it is convenient for the couple. You should not accept the cup and saucer. Itmay have no monetary value, but it may have value for the family. It is unlikely you would be accused of theft, butit is not beyond the realm of possibility. You need to explore the intent of the gift with the couple. Perhaps theyview you as their own child and expect an ongoing personal relationship with you. Perhaps it is part of terminatingthe nurse-client relationship. You can then respond to their intent and gracefully decline the gift, explaining thatyou will always have the memories of the couple, but cannot accept the gift. It is helpful if there is agency policyyou can quote.Scenario 3You have cared for a family during a complicated postpartum hospital stay. The parents are recent immigrants with nofamily and few friends in Canada. You are now preparing them for discharge and referring them for follow-up bycommunity nurses. As the father is shaking your hand and thanking you, he slips you a crisp one hundred dollar bill.When you say you can’t accept it, he insists, “It is nothing. This is our way. It is a sign of respect - you are the baby’sauntie.”DiscussionIn some cultures it is common to give monetary gifts to people who have provided services. Nurses often providean important service to clients at times when they are very vulnerable and have many needs. Perhaps this familywas looking for ways to show their appreciation and used an approach that was usual in their country. In addition,the family had few social supports and had come to consider you part of their family. By calling you “auntie” theymay have an expectation of a continuing relationship with you. You may have missed earlier, more subtle signsthat this family was beginning to consider you a personal friend, but now it is evident and you have to quicklyestablish appropriate nurse-client boundaries with respect to both the money and your relationship to the family.The challenge is to do it with compassion, understanding and respect for them and their cultural background. Youcan begin by saying, “Thank you. It has been a privilege to know you. I am sure it is not easy being so far fromyour family with a new baby. I am glad I could help you, but this is my job and I get paid for my work and Icannot accept this gift, but I do appreciate your thoughtfulness and I wish you all the best in the future.” If thefather continues to insist you accept the money, you need to be clearer. Tell him about the organization’s no-giftpolicy and suggest alternatives such as buying the baby something or making the donation to the hospital’sfoundation or auxiliary. If he asks you to visit the family at home, decline and focus on their needs by explainingthe services the community nurses provide (e.g., “I cannot visit you at home, but the community health nurse willCollege of Registered Nurses of British Columbia 15

NURSE-CLIENT RELATIONSHIPSvisit you tomorrow to see how you are doing. She is very knowledgeable about new babies and new parents. If youneed help before she visits, you can call the BC NurseLine. It provides 24-hour health information and advice.”).MONETARY GAIN OR PERSONAL BENEFITScenario 1You are a single mother struggling to bring up three children. You are also one of five nurses in a small ruralcommunity. As a team, you are providing palliative support to a widow who has a live-in caregiver. Because you liveclosest, you visit most often. When she dies you learn she has a large estate and has left you $100,000. She has norelatives and has left the rest of her estate to charity. Your supervisor says you cannot accept the money and yourcolleagues have all voiced strong opinions.DiscussionWhether a client leaves you a small amount of money or a substantial sum, you cannot accept it. Some mightargue there is no family to dispute the will and that by refusing the bequest, you are denying someone’s last wish.Furthermore, the nurse-client relationship is clearly terminated. However, a bequest is a posthumous gift. Theclient was vulnerable and the nurse was in a position of power. Accepting a bequest is clearly receiving a personalbenefit arising from the nurse-client relationship. It leaves the nurse open to the appearance of exerting undueinfluence or taking advantage of a vulnerable client, even when that was not the intent or the situation. Byassociation, all nurses are implicated, which may explain the reactions of your colleagues. As your supervisorrightly understands, it is never acceptable for a nurse to accept a personal benefit or any monetary gain arisingfrom the nurse-client relationship. You have two options: you can refuse the bequest and it will revert to the estateor you can ask that it be donated to a charitable organization.Scenario 2You are the instructor for a group of nursing students in their last semester. One of the students tells you how great Jim,a senior instructor, is because he has given them his wife’s business card and said she can help them organize theirfinances to deal with their debt load because she is a bank manager. You know Jim is caring and thoughtful andpopular with staff and students. As a junior instructor you feel uncomfortable approaching him and you wonder if youshould say anything to anyone.DiscussionAs instructors, you are both in a position of power over your students. It is also likely they trust and respect you.As instructors it is up to you to develop and maintain boundaries in the teacher-student relationship. While itcould be rationalized that it might be mutually beneficial for the students and the bank, in fact by advertising hiswife’s business Jim is taking advantage of his position. It could result in personal benefit to him. He would notwant to be responsible if the financial management advice did not work out well for any student. You need todiscuss the issue with Jim, but you may first want to talk in confidence to a trusted and knowledgeable colleagueabout the best approach. You need to meet privately with Jim and tell him what you have learned. You can pointout that you believe he cares about students and that his actions were well intended, but you think he has made amistake. You could use the CRNBC practice standard Nurse-Client Relationships to discuss how it applies to the16 College of Registered Nurses of British Columbia

NURSE-CLIENT RELATIONSHIPSteacher-student relationship. Jim may be willing to address the problem by apologizing to the students, using thesituation as an example of how a nurse may cross a boundary with good intentions but not enough considerationof the implications. He should explain to the students that he made an error in judgment and should not havebeen promoting his wife’s business while working as their instructor. He should ask the students to return orthrow out the business card. To make the issue fully transparent, he should also discuss it with his supervisor. If heis unwilling to address the problem, your next step is to talk to your supervisor.HUGGING OR TOUCHINGScenario 1You are a nurse working in a special care nursery. A premature baby has been weaned successfully from the ventilatorand you have just finished giving her a bath. She is crying so you pick her up to cuddle and sing softly to her. You arejust kissing her cheek as her mother arrives to breastfeed her for the first time. She takes one look and runs from thenursery crying. She complains to the supervisor that you are trying to bond with her baby.DiscussionHolding and cuddling is an appropriate and usual comfort measure for a crying baby. Most mothers wouldwelcome a nurse cuddling their baby in their absence. However, you should have anticipated that this particularmother may have been feeling exceptionally vulnerable and anxious because she had been separated from her sickbaby and she had not been able to breastfeed, or perhaps even hold, her baby. Arriving in the nursery to witnessthe closeness between you and her baby made the mother feel further excluded causing great distress. Your nextstep is to try and build the mother’s trust and respect and re-establish appropriate boundaries. You couldapproach the mother and apologize for upsetting her and demonstrate understanding for the mother’s feelings.You can offer to help her get started with breastfeeding. You can use the breastfeeding session to assess andsupport the bonding process between mother and baby. If the mother is still upset another nurse may have to takeover the care of the mother and her baby. In retrospect, you might have anticipated the mother’s anxiety andconcern and created a different type of reception that made the mother feel welcome and wanted. A commentsuch as “Here is your mom! Your baby tells me she is ready for lunch, so your timing is perfect. Let me help youget started.”Scenario 2You are a nurse in a small long-term care facility. You are friendly, warm and outgoing and popular with the residents.An 80-year-old man was admitted a few days ago. You go in to meet him for the first time. You say, “I am Susan.Welcome to your new home.” and you give him a big hug. He shouts, “Don’t touch me. Get out of here.”DiscussionYou appear to lack information about the client and his transition to the facility. You did not approach him as anindividual but you greeted him in the same manner you greet all the residents. You were not sensitive to theproblems he might be having in adapting to a new environment. As you had never met this resident before youCollege of Registered Nurses of British Columbia 17

NURSE-CLIENT RELATIONSHIPSshould have reviewed his chart and approached him in a way to demonstrate respect and establish trust. Insteadyou used your position of power and immediately assumed an intimate relationship with someone you had nevermet. As a next step you should apologize to the resident, then take time to either review his file or do an admissionassessment. Develop an individualized care plan with him and his family.MANAGING PERSONAL AND PROFESSIONAL RELATIONSHIPScenario 1You are the only nurse on nights when one of your neighbours is admitted in active labour, accompanied by her anxioushusband. While she has shared many details of her pregnancy with you, you have never discussed the possibility ofcaring for her in labour.DiscussionCaring for friends or neighbours is generally inadvisable as it may be difficult to maintain the necessary objectivity,particularly if complications arise or painful procedures are required. However, when a woman is in active labourit is not easy to have the sort of discussion necessary. Your neighbour may or may not want you to care for her.You could have broached this issue with her months earlier as in a small unit there was a high likelihood of thishappening. At this point you need to explore if there are any alternative staffing possibilities. If none exist, youneed to briefly outline the situation for your neighbour and her husband and clarify the need for a nurse-clientrelationship until a relief nurse is available. You need to inform your clients that their privacy and confidentialityare assured.Scenario 2You are the nurse manager on a surgical floor. A nurse who is new to the city comes to discuss job opportunities withyou. At this time you have no available positions, but you have a lively and interesting discussion and you file herresume for future reference. The following week you look up her phone number on her resume and consider calling herto go to a movie.DiscussionAs a nurse manager you are in a position of power with respect to potential employees. It would not beappropriate to contact someone on a social basis while you are considering them as a prospective employee. Theprospective employee is vulnerable, particularly if unemployed. She may feel intimidated and may find it difficultto refuse your invitation. As the nurse manager, you are responsible for establishing and maintaining aprofessional relationship with past, present and potential staff members.18 College of Registered Nurses of British Columbia

NURSE-CLIENT RELATIONSHIPSCARING FOR CLOSE FRIENDS OR FAMILYScenario 1You are the triage nurse in a busy emergency department when a neighbour arrives with your 10-year-old child whohas been hit by a car. He has blood on his face. When he sees you he starts sobbing and runs toward you. He is veryworried you are going to be angry. Moments later an ambulance arrives with two major trauma victims.DiscussionYou are caught between your personal and professional roles. You recognize your child may have either minorinjuries or a more serious head injury. In either event, you are likely distraught and unable to continue to carryout your duties as triage nurse in a safe or effective manner. You need to seek immediate relief from your positionso you can attend to your child. Your manager needs to arrange coverage of the triage desk immediately andensure safe dispatch of the trauma patients.Scenario 2You are a nurse and your father has terminal lung cancer. Your family, in consultation with the palliative care team,has decided to care for him at home as long as possible. Family members, including you, all take turns helping himbathe, eat and get up to the bathroom. The palliative care nurse comes in regularly to care for your father and supportthe family. Everyone, including your father, wishes the end would come. Finally he needs injectable morphine morefrequently and you agree to give it.DiscussionAny family member who is willing and able can be taught to give injectable medications. As a nurse you alreadyhave the competence or can refresh your skills quickly. If your father is agreeable, you can give the injectionsaccording to the doctor’s orders and the nurse’s instructions. It is important that you don’t assume the role ofprimary nurse for your father. It is not possible to be both his daughter and his nurse at the same time. The overallresponsibility for caring for your father should remain with the palliative care nurse. You should play a supportiverole.WORKING AND LIVING IN SMALL COMMUNITIESScenario 1You are a nurse practitioner providing primary health care for a small aboriginal community. While you are groceryshopping the husband of a client you saw in the clinic last week asks you if her test results are back yet. You are not surewhich results he is talking about and you are in a hurry.DiscussionWhen nurses work and live in the same small community, people may assume they are always on duty. Nursesneed to be able to set boundaries to protect their personal time. They also need to protect client confidentiality.College of Registered Nurses of British Columbia 19

NURSE-CLIENT RELATIONSHIPSThe husband may be genuinely concerned for his wife or he may be fishing for information about whether sheeven attended the clinic. Except in an emergency, you need to be clear when you are on and off duty andconsistent in letting people know they need to contact you through the clinic for health care. You might say, “Ihave to get groceries now. Please ask your wife to call me in the clinic in the morning if she wants to talk to me.”SELF-DISCLOSUREScenario 1You are the nurse on a surgical unit preparing a 45-year-old woman who is a fitness trainer for a mastectomy. Shebursts into tears and says she feels so alone. She is afraid she will no longer be attractive and she may even die. You arethe same age and had a mastectomy five years ago. You are healthy and work full-time. You remember your ownchallenges coming to terms with the diagnosis of breast cancer and wonder if it would be helpful to share some of yourexperience with her.DiscussionIt is generally not appropriate for nurses to disclose personal information to their clients. However, after carefulconsideration it may be appropriate for you to disclose a limited amount of information to this client. Your firststeps could be to acknowledge your client’s fear, explore her grief and focus on her needs. It may then becomemore apparent if it would be appropriate and timely for you to disclose a limited amount of information aboutyour own breast cancer experience.The intent of your disclosure is to focus on your client’s needs for information, support and hope for the future.For example, because of her concern about feeling “alone” you might say “I was diagnosed with breast cancer fiveyears ago. It was a frightening time. I later discovered I was not alone. There are a number of resources availablefor women with breast cancer. I found the Breast Cancer Support Group particularly helpful, as have many of mypatients.”Scenario 2You are a nurse on the psychiatric unit. Your son committed suicide four months ago and you are seeing a counsellorweekly to help you deal with your grief. Your colleagues have been very supportive over the past month in helping youreturn to work. A woman is admitted to your unit with a reactive depression, following the tragic death of her daughterin a car accident a month ago. You consider sharing your terrible loss with her.DiscussionIt is not appropriate for you to disclose information about your son’s death to this client. You are still grievingdeeply and working to come to terms with his death. With many unresolved issues yourself, it is not timely toshare your tragic loss with a client. It is unlikely in your grief that you could be therapeutic with this client, and itis possible that, without realizing it, you are fulfilling your own needs by telling your story. Whether you shouldeven be caring for this client is a matter for discussion with your manager and counsellor.20 College of Registered Nurses of British Columbia

NURSE-CLIENT RELATIONSHIPSABUSE AND COERCIONScenario 1You are the charge nurse on the weekend on a short-staffed rehabilitation unit. One brain-injured client is particularlyresistant to being hurried through her bath. You walk by the shower room and look in because you hear shouting. Yousee the care aide hit the client on the head with a hair brush. When you speak to the aide she says the client wasstruggling and the hair brush slipped.DiscussionAny form of physical abuse is a violation of the trust the health care facility and the clients put in a staff member. Abrain-injured client is a particularly vulnerable client. Although the care aide is not a professional with standardsof practice and a code of ethics, as the charge nurse you are directly responsible for clients in your care. You sawthe care aide hit the client so you must remove the aide from the situation immediately and ensure the client issafe. You need to document what you saw and call your supervisor for direction in handling this situation further.Scenario 2As a community health nurse, you have been asked by your supervisor to complete a research questionnaire with allmothers who come for the Well Baby Clinic. Your supervisor says it is a requirement before the baby can be seen. Onemother is reluctant to answer some questions which she says are too personal. She is worried you won’t see the baby.DiscussionParticipation in a research project requires informed consent on the part of all participants. There should be noconsequences for clients who refuse to participate in a study or who chose to withdraw at any point in the study.This mother needs to be able to trust that she can get the care her baby needs, free of threats, coercion or pressure.As her nurse and advocate you need to approach your supervisor to clarify the situation and you need to providethe appropriate well baby care without delay. You should also advocate for the necessary research policies andprotocols within the health authority.College of Registered Nurses of British Columbia 21

NURSE-CLIENT RELATIONSHIPSBibliographyBanks, W. (2005). Charting the choppy waters of sexual misconduct. National Review of Medicine, 2.Beach, M., Roter, D., Larson, S., Levinson, W., Ford, D., & Frankel, R. (2004). What do physicians tell patients about themselves? Journal of General Internal Medicine, 19, 911-916.Campbell, C. & Gordon, M. (2003). Acknowledging the inevitable: Understanding multiple relationships in rural practice. Professional Psychology: Research and Practice, 34, 430-434.Canadian Healthcare Association, Canadian Medical Association, Canadian Nurses Association, & Catholic Health Association of Canada. (1999). Joint statement on preventing and resolving ethical conflicts involving health care providers and persons receiving care. Ottawa: Authors.Canadian Nurses Association. (2002). Code of ethics for registered nurses. Ottawa: Author. Available online: www.cna-aiic.caCollege and Association of Registered Nurses of Alberta. (2005). Professional boundaries for registered nurses: guidelines for the nurse-client relationship. Edmonton: Author. Available online: www.nurses.ab.caCollege of Nurses of Ontario. (2006). Therapeutic nurse-client relationship. Toronto: Author. Available online: www.cno.orgCollege of Physicians and Surgeons of British Columbia. (2006). Sexual boundaries in the physician/patient relationship. Vancouver: Author. Available online: www.cpsbc.caCollege of Registered Nurses of British Columbia. (2005). Professional standards for registered nurses and nurse practitioners. Vancouver: Author. Available online: www.crnbc.caCollege of Registered Nurses of British Columbia. (2006). Nurse-client relationships. (Pub. 432). Vancouver: Author. Available online: www.crnbc.caLeBlanc, B. (2006). Receiving gifts from clients or patients: Is it okay? Professional Practice and Liability on the Net, 7.Norris, D., Gutheil, T., & Strasburger, L. (2003). This couldnt happen to me: Boundary problems and sexual misconduct in the psychotherapy relationship. Psychiatric Services, 54, 517-522.Rushton, C.H., Armstrong, L., & McEnhill, M. (1996). Establishing therapeutic boundaries as patient advocates. Pediatric Nursing, 22(3), 185-189.Scopelliti, J., Judd, F., Grigg, M., Hodgins, G., Fraser, C., Hulbert, C. et al. (2004). Dual relationships in mental health practice: Issues for clinicians in rural settings. Australian and New Zealand Journal of Psychiatry, 38, 953-959.Simon, R. & Izben C. (1999). Maintaining treatment boundaries in small communities and rural areas. Psychiatric Services, 50, 1440-1446.Smith, L.L., Taylor, B.B., Keys, A.T., & Gornto, S.B. (1997). Nurse-patient boundaries: Crossing the line. American Journal of Nursing, 97(12), 26-32.Wright Talton, C. (1995). Touch - of all kinds - is therapeutic. RN, February, 61-64.22 College of Registered Nurses of British Columbia

NURSE-CLIENT RELATIONSHIPSResources for NursesCRNBCHelen Randal LibraryCRNBC’s Helen Randal Library is available to registrants to assist with any additional information needs. Currentjournal articles about aspects of nurse-client relationships can be requested. See the Bibliography section forresources used in the development of this book.Confidentiality (Practice Standard - pub. 400)Conflict of Interest (Practice Standard - pub. 439)Duty to Report (Practice Standard - pub. 436)Guidelines for a Quality Practice Environment for Nurses in British Columbia (pub. 409)Nurse-Client Relationships (Practice Standard - pub. 432)Professional Standards for Registered Nurses and Nurse Practitioners (pub. 128)Practice SupportCRNBC provides confidential nursing practice consultation for registrants. Registrants can contact a nursingpractice consultant or regional nursing practice advisor to discuss their concerns related to nurse-clientrelationships. Telephone 604.736.7331 or 1.800.565.6505 (ext. 332).Website - www.crnbc.caCRNBC’s website has a wide range of information for your nursing practice, including practice standards, positionstatements, the Professional Standards for Registered Nurses and Nurse Practitioners, and the Scope of Practice forRegistered Nurses: Standards, Limits and Conditions.Other ResourcesCanadian Nurses Association. (2002). Code of ethics for registered nurses. Ottawa: Author. Available online:www.cna-aiic.caCollege of Nurses of Ontario. (2006). Therapeutic nurse-client relationship. Toronto: Author. www.cno.orgCollege of Registered Nurses of British Columbia 23

Nursing knowledge

by Esther Ying

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