Nursing knowledge

PRACTICE SUPPORT

Nurse-Client Relationships

2855 Arbutus Street,
Vancouver, BC V6J 3Y8
Tel 604.736.7331 or
1.800.565.6505
www.crnbc.ca
Copyright CRNBC/Nov 2006
Pub. No. 406

NURSE-CLIENT RELATIONSHIPS

Contents

Introduction ..........................................................................................................................4

The Nurse-Client Relationship................................................................................................5
ACKNOWLEDGING THE POWER IMBALANCE: CLIENT VULNERABILITY ..................................................... 6
UNDERSTANDING INTERPERSONAL RELATIONSHIPS .......................................................................................6
Personal Relationships............................................................................................................................7
Professional Relationships ......................................................................................................................7

Understanding 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 ........................................................................................................................................13

Applying 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 ...........................................................................................................................................................21

Bibliography..........................................................................................................................22

Resources for Nurses.............................................................................................................23

College of Registered Nurses of British Columbia 3


Introduction
All 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 profession
colleges “to establish . . . a patient relations program to seek to prevent professional misconduct of a sexual
nature.” The College of Registered Nurses of British Columbia (CRNBC) has interpreted the Act broadly to
include 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’s
Professional 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-client
relationships.

In this document, CRNBC provides a more detailed discussion of the boundaries of the nurse-client relationship
and describes the role of nurses1 in maintaining a professional relationship with all clients. It is intended that this
resource will stimulate discussion and guide decision-making about nurse-client relationships in all practice
settings and in all domains of practice. The scenarios found in this booklet outline some of the realities and
complexities faced by nurses in their relationships with clients.2

Can 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


The Nurse-Client Relationship
The nurse-client relationship is professional and therapeutic. It ensures the client’s needs are first and foremost. It
exists to meet the needs of the client, not the needs of the nurse. It is always the nurse who is responsible for
establishing and maintaining boundaries with clients, regardless of how the patient behaves. The components of
the 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.



ACKNOWLEDGING THE POWER IMBALANCE:
CLIENT VULNERABILITY
In the nurse-client relationship, a power imbalance exists. It is usually the nurse who is in a position of power and
the client who is dependent and has less power. The nurse has a broad range of competencies that clients need
including knowledge, authority, influence and access to privileged information about clients. The client has less
ability 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 might
depend on nurses to meet basic needs. Clients may perceive that their health, well-being and safety depend on the
nurse. Clients might not have a network of supportive family and friends and may want to depend on the nurse
beyond the practice setting. Some clients, such as those with mental health problems or those in need of ongoing
care, 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 feel
intimidated and to create a therapeutic relationship. This awareness is a prerequisite to taking further steps to
establish and maintain appropriate boundaries.3 It is always the nurse’s responsibility to maintain the integrity of
the boundary with clients and their significant others. The appropriate use of power in the nurse-client
relationship ensures the client’s needs are foremost and the client’s vulnerability is protected.

UNDERSTANDING INTERPERSONAL RELATIONSHIPS
Interpersonal 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 sexual
relationship. 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 to
have 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 the
differences between a professional and a personal relationship are listed in Table 2. This list is by no means
exhaustive; there are many other factors that also describe the differences between professional and personal
relationships.
It is the nurse’s responsibility to establish and maintain a professional relationship with clients. When a nurse
knows a client through a personal relationship, it may be difficult to maintain sufficient objectivity about the
person to enable the nurse to enter into a professional relationship. Caution is required. Nurses need to be direct
and explicit with clients, potential clients and former clients about the nature of their relationship. Difficulties
arise when there is a lack of clarity about when the relationship is personal and when it is professional. Nurses who
themselves are vulnerable because of difficult circumstances in their own life need to be particularly self-aware and
thoughtful 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.



Personal Relationships
Casual Relationships
Casual relationships arise when nurses, as members of a community, are acquainted with other people in the
normal course of living. A casual relationship is not regarded by anyone as close, romantic or sexual.

Friendships
Friendships 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 meaning
and history for everyone involved, but it is not regarded by anyone as romantic or sexual. Nurses do not enter into
friendships with clients, but they may have a pre-existing friendship with someone who becomes a client.

Romantic or Sexual Relationships
A sexual relationship implies erotic desires or activities, while a romantic relationship generally involves both an
emotional 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 or
romantic relationship with clients, although they may have a pre-existing relationship with someone who later
becomes a client.

Professional Relationships
The professional relationship between nurses and their clients is based on a recognition that clients (or their
alternate decision-makers) are in the best position to make decisions about their own lives when they are active
and informed participants in the decision-making process. These relationships must neither have a negative effect
on meeting a client’s therapeutic needs nor in any way interfere with a client’s right to receive safe, competent and
ethical care.
Maintaining boundaries in professional relationships can be challenging. It is the nurse’s responsibility to set the
boundaries by: self-reflection; following the care plan; meeting personal needs outside the relationship; being
sensitive to context; and initiating, maintaining and terminating the nurse-client relationship appropriately.



Table 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.



Understanding Boundaries in the Nurse-Client Relationship
It is important for nurses to be aware when a professional relationship is slipping into the non-professional realm
and to take immediate action. Nurses do not enter into a friendship or a romantic or sexual relationship with
clients. Nurses are cautious in socializing with clients and/or former clients, especially when the client or former
client 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 of
their colleagues. Any of these behaviours may signal the need for nurses to reflect on the nature of the nurse-client
relationship 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.



In cases where a nurse’s behaviour is unprofessional, it is important to determine if the behaviour reflects a
pattern or is an isolated event only. If there is a pattern of inappropriate behavior or if abuse is involved, then
intervention 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 the
nurse to withdraw from the relationship. Exploring concerns about boundaries with a knowledgeable and trusted
colleague helps nurses to understand their own feelings and motives and recognize their own vulnerabilities. Such
reflection helps makes boundary issues more apparent, helps nurses understand the importance of boundaries and
helps identify strategies for establishing and maintaining boundaries.

CROSSING BOUNDARIES
Some 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 a
betrayal of trust or the misuse of the power imbalance between the nurse and the client. It is unacceptable for
nurses 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 the
nurse or monetary or personal loss to the client are also unacceptable. (See the discussion below on situations that
may create problems with boundaries.)

Other behaviours by the nurse toward clients, while unacceptable in most contexts, may be acceptable and
appropriate in special circumstances. For example, while generally nurses should not disclose information about
themselves to clients, there may be times when select and limited disclosure may be judged helpful in meeting the
therapeutic needs of the client.

While some boundaries are absolute and must never be violated (e.g., any form of abuse of clients), there may be
shades of gray around other boundaries that require the use of good judgment and careful consideration of the
context (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 relationships
with clients may start with something very benign then gradually progress until the nurse has clearly violated a
boundary in the nurse-client relationship and failed to meet the CRNBC Standards for Registered Nursing Practice
in British Columbia, and the CNA Code of Ethics for Registered Nurses. For example, having a casual and
coincidental coffee with a client’s significant other in the hospital cafeteria can become a friendship and then turn
into a romantic relationship.

SITUATIONS THAT MAY CREATE PROBLEMS WITH BOUNDARIES

Giving and Receiving Gifts
Generally, it is not acceptable for nurses and clients to exchange gifts. A group of nurses may give or receive a
token 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 without
compensation. Gifts may be small, such as chocolates, or large, such as a bequest in a will. Gifts have many



different connotations. There may be situations when refusing a gift may be difficult and seem impolite. Gift
giving may be an expectation under certain circumstances or within some cultures. It may be an expression of
gratitude 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 special
treatment of that nurse which can create resentment. The nurse may perceive the gift as pressure from the client to
provide extra care. Other clients may feel under obligation to provide similar gifts. In any case, a gift has the
potential to change the nature of a relationship, depending on how it is intended and how it is perceived. Nurses
need to consider carefully the implications of giving or receiving any gift, including its value, intent and
appropriateness. For the most part, nurses politely decline gifts and they work with their agencies to develop clear
and relevant policies for all staff regarding gifts.

There are some limited circumstances when giving or receiving a gift is acceptable. Generally, it is more acceptable
for 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 Benefit
Nurses have access to personal and confidential information about their clients. It is possible for nurses, who are
unaware 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 misappropriate
money. A nurse could also influence or coerce a client to make decisions resulting in benefit to the nurse or
personal 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 in
their 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 the
nurse may not even know about the bequest until the will is read. Family members or colleagues may perceive that
the nurse has exerted undue influence on vulnerable clients. For these reasons nurses must not accept a bequest of
any nature. As with a gift, the best option is to refuse a bequest with a polite explanation or to reassign it to an
appropriate charitable organization.

For the same reasons, nurses do not act for clients through representation agreements nor do they accept power of
attorney responsibilities to make legal and financial decisions on behalf of their clients. There may occasionally be
an exception to this principle when the client is also a relative or close friend and no alternative arrangement can
be made. The nurse needs to discuss the situation with both her supervisor and other family members.



Hugging or Touching
The nature of nursing involves touching clients. Nurses use both task touch and supportive touch. Task touch is
used to perform procedures or to assist clients with an activity. Supportive touch is touching the client when there
is no physical need. It is used to provide comfort or encouragement and when used effectively it has a calming and
therapeutic effect on the client. There are also formal touch therapies that have distinct techniques and therapeutic
goals.

Nurses may touch or hug children, adult clients or their clients’ significant others in some situations to be
supportive. While it is a therapeutic, human and caring response to a number of situations, such contact has the
potential to be misinterpreted by vulnerable clients. The type, location and amount of touch will vary with the
nurse’s and the client’s age, gender and culture. Nurses need to carefully assess each situation and determine that
supportive touch would be appropriate and welcome. They need to be aware of the client’s perception of the
meaning 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 when
someone 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 nursing
care. If unable to clarify the relationship is professional, the nurse should assign the client to another nurse and
withdraw because a dual role can be problematic, having the potential to create conflict, a loss of objectivity and
harm clients.

For these same reasons, when a professional nurse-client relationship exists it is unacceptable for a nurse to enter
into 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 their
significant others, particularly those clients who are vulnerable or who have the potential to become clients again.

Caring for Close Friends or Family
The problems of a dual role are accentuated when close friends or family members become clients. It is rarely
possible for the nurse to maintain sufficient objectivity about the person to enable a therapeutic nurse-client
relationship. 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 another
appropriate 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 to
have a professional and a personal relationship at the same time. To avoid the confusion of roles and the blurring
of personal and professional boundaries, a nurse is cautious, clarifies the nature of the relationship and carefully
considers the impact of the dual role on the client, the client’s significant others and the nurse. Discussing the dual
role may be difficult for the client as well as the nurse. If the nurse cannot clarify that the relationship is
professional, 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 should



be assigned to another nurse who has only a professional relationship with the client. The nurse with the personal
relationship may play a supportive or secondary role.

Working in Small, Rural or Remote Communities
There is a natural overlap and interdependence of people living in small, rural or remote communities. In small
communities nurses come to know people on a personal basis. When someone from the community becomes a
client, the nurse needs to clarify the shift from a personal to a professional relationship in an open and transparent
way. 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 about
when they are acting in a personal role and when they are acting in a professional role. By establishing these
boundaries 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 discrete
communities within large urban centres (e.g., religious, gay or military communities).

Self-disclosure
Self-disclosure occurs when the nurse shares personal information with a client. Self-disclosure may be used in
moderation as long as it is focused on the needs of the client. In these situations disclosing personal information
may have the therapeutic intent of reassuring, counselling or building rapport with clients. Disclosing personal
information that is lengthy, self-serving or intimate is never acceptable.



Applying the Practice Standard
The following scenarios have been prepared to foster discussion about appropriate and inappropriate behaviours
of nurses in the context of the nurse-client relationship. The following questions should be considered when
thinking 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 GIFTS

Scenario 1
You are a nurse working on a pediatric floor. A five-year-old child with a chronic disease was admitted a month ago
and you have become particularly attached to him. He is bright and brave, but comes from a poor family. His parents
can 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 colleagues
appear angry and resentful.
Discussion
In your enthusiasm to do something special for a disadvantaged child, you independently singled out an
individual 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, personal
relationship beyond the boundaries of the nurse-client relationship. Your colleagues may have felt resentful for
several reasons, including having been excluded from the plan and seeing unreasonable expectations being
established on the unit. The reaction of the parents to their child receiving an expensive gift is not known. The gift
and cake may create an element of mistrust if the parents are concerned about you putting them at a disadvantage
and alienating their child’s affection. You now need to meet with your colleagues to discuss the issue. The pediatric
unit would benefit from establishing a policy about celebrating all children’s birthdays. Such a policy might
include 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.



Scenario 2
You have been caring for an elderly couple at home periodically for many years. Often they serve you a cup of tea and a
cookie before you go to your next client. You consider it your coffee break and it gives the couple some much needed
social contact. One day the woman gives you the tea cup and saucer to take home. She says, “Because it is yours. You
always use it. We are giving away things we can’t take to the nursing home.” When you mention the incident to a
colleague she says, “You should never have taken it. They might later accuse you of theft. In fact, you shouldn’t even
accept a cup of tea.”
Discussion
Accepting a cup of tea and taking time to socialize with this couple can be considered part of the therapeutic plan
but 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. It
may have no monetary value, but it may have value for the family. It is unlikely you would be accused of theft, but
it is not beyond the realm of possibility. You need to explore the intent of the gift with the couple. Perhaps they
view you as their own child and expect an ongoing personal relationship with you. Perhaps it is part of terminating
the nurse-client relationship. You can then respond to their intent and gracefully decline the gift, explaining that
you will always have the memories of the couple, but cannot accept the gift. It is helpful if there is agency policy
you can quote.

Scenario 3
You have cared for a family during a complicated postpartum hospital stay. The parents are recent immigrants with no
family and few friends in Canada. You are now preparing them for discharge and referring them for follow-up by
community 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’s
auntie.”

Discussion
In some cultures it is common to give monetary gifts to people who have provided services. Nurses often provide
an important service to clients at times when they are very vulnerable and have many needs. Perhaps this family
was 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” they
may have an expectation of a continuing relationship with you. You may have missed earlier, more subtle signs
that this family was beginning to consider you a personal friend, but now it is evident and you have to quickly
establish 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. You
can begin by saying, “Thank you. It has been a privilege to know you. I am sure it is not easy being so far from
your 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 I
cannot accept this gift, but I do appreciate your thoughtfulness and I wish you all the best in the future.” If the
father continues to insist you accept the money, you need to be clearer. Tell him about the organization’s no-gift
policy and suggest alternatives such as buying the baby something or making the donation to the hospital’s
foundation or auxiliary. If he asks you to visit the family at home, decline and focus on their needs by explaining
the services the community nurses provide (e.g., “I cannot visit you at home, but the community health nurse will



visit you tomorrow to see how you are doing. She is very knowledgeable about new babies and new parents. If you
need help before she visits, you can call the BC NurseLine. It provides 24-hour health information and advice.”).

MONETARY GAIN OR PERSONAL BENEFIT

Scenario 1
You are a single mother struggling to bring up three children. You are also one of five nurses in a small rural
community. As a team, you are providing palliative support to a widow who has a live-in caregiver. Because you live
closest, you visit most often. When she dies you learn she has a large estate and has left you $100,000. She has no
relatives and has left the rest of her estate to charity. Your supervisor says you cannot accept the money and your
colleagues have all voiced strong opinions.

Discussion
Whether a client leaves you a small amount of money or a substantial sum, you cannot accept it. Some might
argue 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. The
client was vulnerable and the nurse was in a position of power. Accepting a bequest is clearly receiving a personal
benefit arising from the nurse-client relationship. It leaves the nurse open to the appearance of exerting undue
influence or taking advantage of a vulnerable client, even when that was not the intent or the situation. By
association, all nurses are implicated, which may explain the reactions of your colleagues. As your supervisor
rightly understands, it is never acceptable for a nurse to accept a personal benefit or any monetary gain arising
from the nurse-client relationship. You have two options: you can refuse the bequest and it will revert to the estate
or you can ask that it be donated to a charitable organization.

Scenario 2
You 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 their
finances to deal with their debt load because she is a bank manager. You know Jim is caring and thoughtful and
popular with staff and students. As a junior instructor you feel uncomfortable approaching him and you wonder if you
should say anything to anyone.
Discussion
As 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 it
could be rationalized that it might be mutually beneficial for the students and the bank, in fact by advertising his
wife’s business Jim is taking advantage of his position. It could result in personal benefit to him. He would not
want to be responsible if the financial management advice did not work out well for any student. You need to
discuss the issue with Jim, but you may first want to talk in confidence to a trusted and knowledgeable colleague
about the best approach. You need to meet privately with Jim and tell him what you have learned. You can point
out that you believe he cares about students and that his actions were well intended, but you think he has made a
mistake. You could use the CRNBC practice standard Nurse-Client Relationships to discuss how it applies to the



teacher-student relationship. Jim may be willing to address the problem by apologizing to the students, using the
situation as an example of how a nurse may cross a boundary with good intentions but not enough consideration
of the implications. He should explain to the students that he made an error in judgment and should not have
been promoting his wife’s business while working as their instructor. He should ask the students to return or
throw out the business card. To make the issue fully transparent, he should also discuss it with his supervisor. If he
is unwilling to address the problem, your next step is to talk to your supervisor.

HUGGING OR TOUCHING

Scenario 1
You are a nurse working in a special care nursery. A premature baby has been weaned successfully from the ventilator
and you have just finished giving her a bath. She is crying so you pick her up to cuddle and sing softly to her. You are
just kissing her cheek as her mother arrives to breastfeed her for the first time. She takes one look and runs from the
nursery crying. She complains to the supervisor that you are trying to bond with her baby.

Discussion
Holding and cuddling is an appropriate and usual comfort measure for a crying baby. Most mothers would
welcome a nurse cuddling their baby in their absence. However, you should have anticipated that this particular
mother may have been feeling exceptionally vulnerable and anxious because she had been separated from her sick
baby and she had not been able to breastfeed, or perhaps even hold, her baby. Arriving in the nursery to witness
the closeness between you and her baby made the mother feel further excluded causing great distress. Your next
step is to try and build the mother’s trust and respect and re-establish appropriate boundaries. You could
approach 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 and
support the bonding process between mother and baby. If the mother is still upset another nurse may have to take
over the care of the mother and her baby. In retrospect, you might have anticipated the mother’s anxiety and
concern and created a different type of reception that made the mother feel welcome and wanted. A comment
such as “Here is your mom! Your baby tells me she is ready for lunch, so your timing is perfect. Let me help you
get started.”

Scenario 2
You 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.”

Discussion

You appear to lack information about the client and his transition to the facility. You did not approach him as an
individual but you greeted him in the same manner you greet all the residents. You were not sensitive to the
problems he might be having in adapting to a new environment. As you had never met this resident before you



should have reviewed his chart and approached him in a way to demonstrate respect and establish trust. Instead
you used your position of power and immediately assumed an intimate relationship with someone you had never
met. As a next step you should apologize to the resident, then take time to either review his file or do an admission
assessment. Develop an individualized care plan with him and his family.

MANAGING PERSONAL AND PROFESSIONAL RELATIONSHIP

Scenario 1
You are the only nurse on nights when one of your neighbours is admitted in active labour, accompanied by her anxious
husband. While she has shared many details of her pregnancy with you, you have never discussed the possibility of
caring for her in labour.

Discussion

Caring 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 labour
it 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 this
happening. At this point you need to explore if there are any alternative staffing possibilities. If none exist, you
need to briefly outline the situation for your neighbour and her husband and clarify the need for a nurse-client
relationship until a relief nurse is available. You need to inform your clients that their privacy and confidentiality
are assured.

Scenario 2
You are the nurse manager on a surgical floor. A nurse who is new to the city comes to discuss job opportunities with
you. At this time you have no available positions, but you have a lively and interesting discussion and you file her
resume for future reference. The following week you look up her phone number on her resume and consider calling her
to go to a movie.
Discussion

As a nurse manager you are in a position of power with respect to potential employees. It would not be
appropriate to contact someone on a social basis while you are considering them as a prospective employee. The
prospective employee is vulnerable, particularly if unemployed. She may feel intimidated and may find it difficult
to refuse your invitation. As the nurse manager, you are responsible for establishing and maintaining a
professional relationship with past, present and potential staff members.



CARING FOR CLOSE FRIENDS OR FAMILY

Scenario 1
You are the triage nurse in a busy emergency department when a neighbour arrives with your 10-year-old child who
has been hit by a car. He has blood on his face. When he sees you he starts sobbing and runs toward you. He is very
worried you are going to be angry. Moments later an ambulance arrives with two major trauma victims.

Discussion

You are caught between your personal and professional roles. You recognize your child may have either minor
injuries or a more serious head injury. In either event, you are likely distraught and unable to continue to carry
out your duties as triage nurse in a safe or effective manner. You need to seek immediate relief from your position
so you can attend to your child. Your manager needs to arrange coverage of the triage desk immediately and
ensure safe dispatch of the trauma patients.

Scenario 2
You 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 him
bathe, eat and get up to the bathroom. The palliative care nurse comes in regularly to care for your father and support
the family. Everyone, including your father, wishes the end would come. Finally he needs injectable morphine more
frequently and you agree to give it.

Discussion

Any family member who is willing and able can be taught to give injectable medications. As a nurse you already
have the competence or can refresh your skills quickly. If your father is agreeable, you can give the injections
according to the doctor’s orders and the nurse’s instructions. It is important that you don’t assume the role of
primary nurse for your father. It is not possible to be both his daughter and his nurse at the same time. The overall
responsibility for caring for your father should remain with the palliative care nurse. You should play a supportive
role.

WORKING AND LIVING IN SMALL COMMUNITIES

Scenario 1
You are a nurse practitioner providing primary health care for a small aboriginal community. While you are grocery
shopping the husband of a client you saw in the clinic last week asks you if her test results are back yet. You are not sure
which results he is talking about and you are in a hurry.

Discussion

When nurses work and live in the same small community, people may assume they are always on duty. Nurses
need to be able to set boundaries to protect their personal time. They also need to protect client confidentiality.



The husband may be genuinely concerned for his wife or he may be fishing for information about whether she
even attended the clinic. Except in an emergency, you need to be clear when you are on and off duty and
consistent in letting people know they need to contact you through the clinic for health care. You might say, “I
have 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-DISCLOSURE

Scenario 1
You are the nurse on a surgical unit preparing a 45-year-old woman who is a fitness trainer for a mastectomy. She
bursts into tears and says she feels so alone. She is afraid she will no longer be attractive and she may even die. You are
the same age and had a mastectomy five years ago. You are healthy and work full-time. You remember your own
challenges coming to terms with the diagnosis of breast cancer and wonder if it would be helpful to share some of your
experience with her.

Discussion

It is generally not appropriate for nurses to disclose personal information to their clients. However, after careful
consideration it may be appropriate for you to disclose a limited amount of information to this client. Your first
steps could be to acknowledge your client’s fear, explore her grief and focus on her needs. It may then become
more apparent if it would be appropriate and timely for you to disclose a limited amount of information about
your 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 five
years ago. It was a frightening time. I later discovered I was not alone. There are a number of resources available
for women with breast cancer. I found the Breast Cancer Support Group particularly helpful, as have many of my
patients.”

Scenario 2
You are a nurse on the psychiatric unit. Your son committed suicide four months ago and you are seeing a counsellor
weekly to help you deal with your grief. Your colleagues have been very supportive over the past month in helping you
return to work. A woman is admitted to your unit with a reactive depression, following the tragic death of her daughter
in a car accident a month ago. You consider sharing your terrible loss with her.
Discussion

It is not appropriate for you to disclose information about your son’s death to this client. You are still grieving
deeply and working to come to terms with his death. With many unresolved issues yourself, it is not timely to
share your tragic loss with a client. It is unlikely in your grief that you could be therapeutic with this client, and it
is possible that, without realizing it, you are fulfilling your own needs by telling your story. Whether you should
even be caring for this client is a matter for discussion with your manager and counsellor.



ABUSE AND COERCION

Scenario 1
You are the charge nurse on the weekend on a short-staffed rehabilitation unit. One brain-injured client is particularly
resistant to being hurried through her bath. You walk by the shower room and look in because you hear shouting. You
see the care aide hit the client on the head with a hair brush. When you speak to the aide she says the client was
struggling and the hair brush slipped.

Discussion

Any form of physical abuse is a violation of the trust the health care facility and the clients put in a staff member. A
brain-injured client is a particularly vulnerable client. Although the care aide is not a professional with standards
of practice and a code of ethics, as the charge nurse you are directly responsible for clients in your care. You saw
the care aide hit the client so you must remove the aide from the situation immediately and ensure the client is
safe. You need to document what you saw and call your supervisor for direction in handling this situation further.

Scenario 2
As a community health nurse, you have been asked by your supervisor to complete a research questionnaire with all
mothers who come for the Well Baby Clinic. Your supervisor says it is a requirement before the baby can be seen. One
mother is reluctant to answer some questions which she says are too personal. She is worried you won’t see the baby.

Discussion

Participation in a research project requires informed consent on the part of all participants. There should be no
consequences 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 provide
the appropriate well baby care without delay. You should also advocate for the necessary research policies and
protocols within the health authority.



Bibliography
Banks, 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.ca
College 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.ca
College of Nurses of Ontario. (2006). Therapeutic nurse-client relationship. Toronto: Author. Available online:
www.cno.org
College of Physicians and Surgeons of British Columbia. (2006). Sexual boundaries in the physician/patient
relationship. Vancouver: Author. Available online: www.cpsbc.ca
College of Registered Nurses of British Columbia. (2005). Professional standards for registered nurses and nurse
practitioners. Vancouver: Author. Available online: www.crnbc.ca
College of Registered Nurses of British Columbia. (2006). Nurse-client relationships. (Pub. 432). Vancouver:
Author. Available online: www.crnbc.ca
LeBlanc, 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 couldn't 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.



Resources for Nurses
CRNBC
Helen Randal Library
CRNBC’s Helen Randal Library is available to registrants to assist with any additional information needs. Current
journal articles about aspects of nurse-client relationships can be requested. See the Bibliography section for
resources 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 Support
CRNBC provides confidential nursing practice consultation for registrants. Registrants can contact a nursing
practice consultant or regional nursing practice advisor to discuss their concerns related to nurse-client
relationships. Telephone 604.736.7331 or 1.800.565.6505 (ext. 332).

Website - www.crnbc.ca
CRNBC’s website has a wide range of information for your nursing practice, including practice standards, position
statements, the Professional Standards for Registered Nurses and Nurse Practitioners, and the Scope of Practice for
Registered Nurses: Standards, Limits and Conditions.

Other Resources
Canadian Nurses Association. (2002). Code of ethics for registered nurses. Ottawa: Author. Available online:
www.cna-aiic.ca
College of Nurses of Ontario. (2006). Therapeutic nurse-client relationship. Toronto: Author. www.cno.org


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