Nurse Client Relationships

8/8/2019 Nurse Client Relationships

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PRACTICE SUPPORT

Nurse-Client Relationships


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


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N U R S E - C L I E N T R E L A T I O N S H I P S

College of Registered Nurses of British Columbia 3

Contents

Introduction ..........................................................................................................................4The Nurse-Client Relationship................................................................................................5

ACKNOWLEDGING THE POWER IMBALANCE: CLIENT VULNERABILITY.....................................................6UNDERSTANDING INTERPERSONAL RELATIONSHIPS .......................................................................................6

Personal Relationships............................................................................................................................7Professional Relationships ......................................................................................................................7

Understanding Boundaries in the Nurse-Client Relationship ..................................................9CROSSING BOUNDARIES................................................................................................................................10SITUATIONS THAT MAY CREATE PROBLEMS WITH BOUNDARIES......................................................................10

Giving and Receiving Gifts .......................................................................................................................10Monetary Gain or Personal Benefit...........................................................................................................11Hugging or Touching................................................................................................................................12Managing Personal and Professional Relationships (dual roles)...............................................................12Self-disclosure ........................................................................................................................................13

Applying the Practice Standard..............................................................................................14GIVING AND RECEIVING GIFTS.........................................................................................................................14MONETARY GAIN OR PERSONAL BENEFIT ........................................................................................................16HUGGING OR TOUCHING ................................................................................................................................17MANAGING PERSONAL AND PROFESSIONAL RELATIONSHIP............................................................................18CARING FOR CLOSE FRIENDS OR FAMILY.........................................................................................................19WORKING AND LIVING IN SMALL COMMUNITIES.............................................................................................19SELF-DISCLOSURE..........................................................................................................................................20

ABUSE ...........................................................................................................................................................21Bibliography..........................................................................................................................22 Resources for Nurses.............................................................................................................23


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4 College of Registered Nurses of British Columbia

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 sexualnature. 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 StandardNurse-

Client Relationships, which sets out the requirements for nursing practice in this area. Further, CRNBCs

Professional Standards for Registered Nurses and Nurse Practitioners and the Canadian Nurses Associations

(CNAs) 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 clients 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.


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The Nurse-Client Relationship

The nurse-client relationship is professional and therapeutic. It ensures the clients 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 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 its especially important that a nurse keep promises to aclient. 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 nursesprovide. 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 clients personal information also

contributes to professional intimacy.

Empathy. Empathy is the expression of understanding, validating and resonating with the meaningthat 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 notimmediately 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 clients significant others. The appropriate use of power, in a

caring manner, enables the nurse to partner with the client to meet the clients needs. A misuse of

power is considered abuse.

College of Nurses of Ontario. (2006). Therapeutic nurse-client relationship. Toronto: Author.


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A C K N O W L E D G I N G T H E P O W E R I M B A L A N C E :

C L I E N T V U L N E R A B I L I T Y

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 nurses responsibility to maintain the integrity ofthe boundary with clients and their significant others. The appropriate use of power in the nurse-client

relationship ensures the clients needs are foremost and the clients vulnerability is protected.

U N D E R S T A N D I N G I N T E R P E R S O N A L R E L A T I O N S H I P S

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.

CRNBCs 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 nurses 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, andnon-professional and personal. When a nurse crosses a boundary, the nurse is behaving in an unprofessional manner andmisuses the power in the relationship.


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Personal Relationships

Casual RelationshipsCasual 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.

FriendshipsFriendships or platonic relationships may exist between a nurse and a client, a clients 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 RelationshipsA 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 orromantic 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 clients therapeutic needs nor in any way interfere with a clients right to receive safe, competent and

ethical care.

Maintaining boundaries in professional relationships can be challenging. It is the nurses 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.


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Table 2: Differences between Professional and Personal RelationshipsCharacteristic Professional Relationship(nurse-client)

Personal Relationship(casual, friendship, romantic, sexual)

Behaviour Regulated by a code of ethics andprofessional standards.

Guided by personal values andbeliefs.

Remuneration Nurse is paid to provide care to client. No payment for being in therelationship.

Length of relationship Time-limited for the length of the

clients need for nursing care.May last a lifetime.

Location of relationship Place defined and limited to wherenursing care is provided. Place unlimited; often undefined.

Purpose of relationship Goal-directed to provide care to client. Pleasure, interest-directed.

Structure of

relationshipNurse provides care to client. Spontaneous, unstructured.

Power of balance Unequal: nurse has more power dueto authority, knowledge, influenceand access to privileged information

about client.

Relatively equal.

Responsibility forrelationship

Nurse (not client) responsible forestablishing and maintainingprofessional relationship.

Equal responsibility to establishand maintain.

Preparation forrelationship

Nurse requires formal knowledge,preparation, orientation and training.

Does not require formal knowledge,preparation, orientation andtraining.

Time spent in

relationship

Nurse employed under contractual

agreement that outlines hours of workfor contact between the nurse andclient.

Personal choice for how much time

is spent in the relationship.

Adapted from: British Columbia Rehabilitation Society (now known as the Vancouver Hospital & Health Sciences Centre). 1992.


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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 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 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 clients care around the clients needs. Seeking social contact or spending free time with the client. Sharing personal information or work concerns with the client. Feeling worried about the clients or familys view of the nurse as a person if their expectations are

not met.

Feeling so strongly about the clients goals that colleagues comments or clients/familys wishesare disregarded.

Feeling responsible for the clients limited progress. Feeling unusual irritation if someone or something in the system creates a barrier or delay in the

clients 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.


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In cases where a nurses 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 trustedcolleague 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.

C R O S S I N G B O U N D A R I E S

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 neverbe 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 clients significant other in the hospital cafeteria can become a friendship and then turn

into a romantic relationship.

S I T U A T I O N S T H A T M A Y C R E A T E P R O B L E M S W I T H B O U N D A R I E S

Giving and Receiving GiftsGenerally, 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


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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 abox 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 maygive a small gift to hospitalized children on their birthday.

Gifts from clients may be accepted through a charitable organization and used directly or indirectly tobenefit 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 hospitals 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 misappropriatemoney. 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 ofattorney 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.


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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

nurses and the clients 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 clients perception of the

meaning of the touch. The perception and response of the clients 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 clients 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 FamilyThe 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 maywantto 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 clients 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 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


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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 CommunitiesThere 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 clients 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.


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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 areinvolved?

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 clients significant other or family? Is the employer aware the nurse is performing the activity and what is the agencys policy related to the

activity?

What kinds of intimate activities might the nurse be expected to perform that might create a personal andprivate 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?

G I V I N G A N D R E C E I V I N G G I F T S

Scenario 1You 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 didnt you give me a present? Your colleagues

appear angry and resentful.

DiscussionIn 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 disadvantageand alienating their childs 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 childrens 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 childs parents,

noting your good intent, but acknowledging you overstepped the boundaries of the nurse-client relationship.


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Scenario 2You 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 cant 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 shouldnt even

accept a cup of tea.

DiscussionAccepting 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 thatyou 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 3You 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 cant accept it, he insists, It is nothing. This is our way. It is a sign of respect - you are the babys

auntie.

DiscussionIn 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 Icannot 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 organizations no-gift

policy and suggest alternatives such as buying the baby something or making the donation to the hospitals

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


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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.).

M O N E T A R Y G A I N O R P E R S O N A L B E N E F I T

Scenario 1You 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.

DiscussionWhether 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 someones 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 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 wifes 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.

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 it

could be rationalized that it might be mutually beneficial for the students and the bank, in fact by advertising his

wifes 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 standardNurse-Client Relationships to discuss how it applies to the


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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 wifes 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.

H U G G I N G O R T O U C H I N G

Scenario 1You 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.

DiscussionHolding 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 mothers trust and respect and re-establish appropriate boundaries. You could

approach the mother and apologize for upsetting her and demonstrate understanding for the mothers 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 mothers anxiety andconcern 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 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, Dont 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 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


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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.

M A N A G I N G P E R S O N A L A N D P R O F E S S I O N A L R E L A T I O N S H I P

Scenario 1You 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.

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 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 2You 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 herresume for future reference. The following week you look up her phone number on her resume and consider calling her

to go to a movie.

DiscussionAs 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.


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C A R I N G F O R C L O S E F R I E N D S O R F A M I L Y

Scenario 1You 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 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 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 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 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.

DiscussionAny 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 doctors orders and the nurses instructions. It is important that you dont 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 overallresponsibility for caring for your father should remain with the palliative care nurse. You should play a supportive

role.

W O R K I N G A N D L I V I N G I N S M A L L C O M M U N I T I E S

Scenario 1You 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.

DiscussionWhen 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.


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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.

S E L F - D I S C L O S U R E

Scenario 1You 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.

DiscussionIt 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 clients 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 clients 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 2You 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.

DiscussionIt is not appropriate for you to disclose information about your sons 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.


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A B U S E A N D C O E R C I O N

Scenario 1You 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. Yousee 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.

DiscussionAny 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 2As 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 wont see the baby.

DiscussionParticipation 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 andprotocols within the health authority.


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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.


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Resources for Nurses

CRNBCHelen Randal LibraryCRNBCs 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 SupportCRNBC 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.caCRNBCs 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 ResourcesCanadian 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

Documents

Nurse Client Relationships