16

Nurse – Patient Relationship

ROLES OF THE NURSE

As you use the nursing process daily with the patient or family in later maturity, you will be functioning in a variety of nursing roles.  You will be responsible for physical care, technical procedures and for creating an environment that is safe, comfortable, stimulating and health promoting.  You will often be called upon to teach informally and formally to enable the patient or family to manage self-care, learn about his or her illness, or response to a situation or better cope with his/her condition.  Referral to other sources of help may be necessary, for no one health team member can meet all the patient’s needs.  You may serve as counselor and you can always serve as a source of emotional and social stimulation and support.  Depending upon your behavior and the senior’s needs, you may be seen as a parental figure.

All of us need loving contact with other people in order to stay human in the fullest sense.  From the moment of birth, the infant cannot survive unless he or she is cared for by the nurturing person.  Likewise, the elderly person cannot survive either, emotionally or physically, unless someone cares about him or her.  Caring is essential to a relationship.

How the senior reacts to you, your attitudes, appearance and behavior will be influenced, at least initially, by past experiences with people.  If experiences have been pleasant with others, he or she will respond more quickly to your caring.  If he/she has primarily felt anxiety and tension in his/her contact with others, he/she is likely to be distant, to respond slowly or even to not respond at all and tell you to go away.  He/she may also test your intentions with overtly obnoxious behavior.  However, underlying this apparent rejection of you, there is usually a great need for interpersonal contact.  Knowing this should stimulate you to continue to reach out, to care.

Important in the total care of the senior is the establishment and maintenance of a relationship.  Your goals may be limited because you cannot always change the person’s pathology and you cannot reverse the aging process.  However, you can help him/her to accept and understand his/her situation; help him/her to find meaning in his/her life and to enjoy personal growth from the experience.  This total care involves not only physical care, but also genuine concern for the patients’ feeling of self-worth, regardless of social values or capacity for achievement.

The elderly patient presents the nurse with a variety of challenges and dilemmas.  The medical problems of the elderly are usually vary complex and require a great deal of time and energy to help solve.  The problems or obstacles encountered with treating the elderly are numerous.  Society holds many negative opinions and beliefs concerning the elderly.  The nurse must overcome these stereotypes and negative beliefs in order to effectively treat the patient.

The elderly patient has certain rights to medical and nursing care.

These rights are the same as any other patient:

1.          The right to assessment.

2.          The right of personal autonomy.

3.          The right to participate in health care decision-making.

These rights indicate that the elderly have the right to be treated just like any other adult patient.  They are not to be treated like babies.  There are many aspects of these rights that are under controversy today.  This includes the right to die, quality of care, quality of life, Medicare and financial aspects, withholding treatment, patient dignity and others.  The nurse will certainly face ethical and moral dilemmas in the near future concerning these rights.  The nurse will have to be aware of these rights and be aware of court decisions affecting the care of the elderly in order to continue a therapeutic nurse-patient relationship.

Relationship can be defined as an interpersonal process in which one person facilitates the personal development or growth of another.  The process takes place over a period of time.  The process involves helping the other person to mature, to become more adaptive, more integrated and to open his or her own experience; or to find meaning in his/her present situation.

The nurse-patient relationship results from a series of interactions between a nurse and patient over a period of time.  The nurse will focus on the needs and problems of the person or family while using the scientific knowledge and specific skills of the profession.  This helping relationship develops through interest in, encounter with and commitment to the person.

CHARACTERISTICS OF THE HELPING PERSON

The capacity to be a helping person is strengthened by a genuine desire to be responsible and sensitive to another person.  In addition, experience with a variety of people increases your awareness of others’ reactions and feelings.  The feedback you receive from others will teach you a great deal on both the emotional level and cognitive levels.

Characteristics of a helping person include:  being……

 

There are several more characteristics that correlate highly with being effective in a helping relationship.  One characteristic is being open, instead of closed, in interaction with others.  An additional characteristic is perceiving others a friendly and capable, instead of unfriendly and incapable.  Another characteristic is that of perceiving a relationship as freeing, instead of controlling another.

Establishing and maintaining a relationship or counseling another, does not involve putting on a façade of behavior to match a list of characteristics.  Rather, both you and, the patient will change and continue to mature.  As the helper, you are present as a total person.  You blend potentials, talents and skills.  You do this while assisting the elderly patient to come to grips with his/her needs, conflicts and self (Rogers 1976).

Working with another in a helping relationship is challenging and rewarding.  You will not always have all the characteristics just described.  At times, you will be handling personal stresses that will lower your energy and sense of involvement.  You may become irritated and impatient while working with the elderly client.  Accept the fact that you are not perfect and that you are always in the process of becoming.

Analyzing your behavior in relation to the person or family can help you determine your effect on them and can help you to be more effective.  Just as you help the senior to develop, you will also continue to expand your personality to better gain the above characteristics.  As you open a panorama of possibilities to another, your own potential unfolds.  Remember that the most important thing you can share with a patient is your own uniqueness as a person.

Nursing experience in itself can bring about a cool efficiency, an overt indifference and an impersonal attitude and environment for the patient.  The distant behavior that may result when the nurse is not rewarded by the work system for demonstrating helping characteristics seems to be an occupational hazard of nursing.  Yet, in an increasingly mechanical world, we have to remain human and treat our patients as human (Pollak 1976).

CHARACTERISTICS OF THE HELPING RELATIONSHIP

1. RAPPORT

A relationship begins with the ability to establish rapport, creating a sense of harmony between individuals.  In order to establish rapport quickly, you must have the following social skills (Rogers 1976).

a.           A warm, friendly manner, appropriate smile and comfortable eye contact.

b.          Ability to treat the other as an equal, to eliminate social barriers, to convey acceptance and to promote a sense of trust.

c.          Ability to find a common interest or experience.

d.          Ability to show a keen, sympathetic interest in the other, to give him or her full attention, to listen carefully and to indicate there is plenty of time.

e.           Ability to accurately adopt his/her terminology and conventions and to meet him/her on his own ground.

2. TRUST

Trust is the firm belief in the honesty, integrity, reliability and justice of another person without fear of outcome, the inner certainty that the other person’s behavior is predictable under a given set of circumstances (Rogers 1976).

The capacity to develop a trusting relationship is built upon your attitude toward people, your flexibility in responding and what you are personally.  Techniques and knowledge are not enough.  You will learn through experience what aspects of your personality are more effective with, and helpful to, others.

Trust is based upon consistency rather than compatibility.  The senior cannot reveal him or herself nor share important information unless he/she can rely upon you.  He must believe that you will react with the same behavioral characteristics each time he or she meets with you.  He/she needs to know that you will keep content from the interview confidential, as mutually agreed upon.  You may have to delay obtaining certain information until a sense of trust is established.  This is because the elderly patient may feel very threatened by an interview or examination.  In addition, you must feel that you can predict the person’s behavior because you have an understanding of the person (Rogers 1976).

3. UNCONDITIONAL POSITIVE REGARD AND ACCEPTANCE

Two qualities often described as essential to a relationship are positive, warm feelings and acceptance.  Is it possible to give expert and professional care and not feel positively toward your patient?  Most patients would say “NO”.  The human spirit loses its sense of vitality and even the will to live when surrounded by hostile persons.

Realistically, it is not possible to like everyone.  Similarly, it is not possible to establish and maintain a relationship with everyone.  However, you will find some patients you will be genuinely interested in and can feel affection for.  Likewise, other nurses will respond the same way to other patients.  There are a few “cantankerous” or “repulsive” people whom no one seems to feel any rapport with or interest in.  Perhaps your willingness to reach out will make a difference.  Your ability to stimulate a more likable behavior in that person may also make a difference.  Also your willingness to learn more about his or her uniqueness, will be the result of our unconditional positive regard, belief in the dignity, worth and importance of the person, regardless of his or her behavior (Murray 1980 (Pollak 1976).

4. EMPATHY

Unconditional positive regard and acceptance are easier to achieve if you have developed empathetic understanding of people.  Empathy is feeling with the person and simultaneously understanding the dynamics of his or her behavior.  As you and the senior feel and think together, your feelings for him or her impels you to act.

Empathy is the ability to sense the patient’s private world as if it were your own.  You can do this without ever losing the “as if” quality.  You can sense the patient’s anger, fear or confusion as if it were your own.  You can do this without your own feelings getting bound up in the interaction.

You are empathetic to the degree that you are able to abstract from your own life experience, by way of recall or generalizations, common factors that are applicable to the patient’s problems.

Certain qualities enhance empathetic skills.  The ability to empathize varies with the patient, time and nurse.  Certainly, a general interest in people, basic knowledge of human behavior and a warm, flexible personality encourages empathy.

Other characteristics that enable you to be more empathetic are:

·              Similarity in values, experiences, social class, culture, economic level, religion, age, personality or sameness of sex.

·              Ability to be alert, to listen with the “third ear”, to become involved in another, to abandon self-consciousness.

·              Ability to cope with egocentricity, anxiety, fears, feelings or stresses that block listening to and feeling with another.

·              Variety of life experiences that help you to acquire a broad understanding of people, flexibility and spontaneity.

·              Ability to maintain an adequate health and energy level.

·              Ability to interpret correctly and to avoid distorting perceptions.

        Empathy involves the following dimensions:

·              Tone – expressing warmth and spontaneity nonverbally and verbally.

·              Pace – timing remarks or behavior appropriate to the patient’s feelings and needs.

·              Perception – abstracting the core or essential meaning of patient concerns; discussing them with him/her in acceptable terms.

·              Leading – formulating questions or statements that move the interview in the direction of the patient’s concerns.

      Empathy is not the same as sympathy or pity:

·              The sympathetic person becomes stricken with emotion because he or she projects himself or herself into the other person’s place.  The empathetic person shares the experience but maintains objectivity.  The sympathizer may be secretly happy that a certain situation has not occurred to him/her, or he/she may feel guilty in his/her own good fortune.  Empathy can be found in any situation, in grief, in joy.

Pity is contrary to helping.  To cause another to feel like a victim debases the person right now.  It also conveys that he will remain debased and helpless.  Pity conveys that the other person receives help because you are obligated and pseudo altruistic.  Spontaneous and genuine helping is “one-on-one” human being with another, simply because you are both human.

How do you communicate empathy?  Use verbal and nonverbal communication so that the senior experiences a feeling of being understood.  Your statements serve as an emotional mirror or as a reflection of his or her feelings without distorting or giving him or her advice.  For example, you may say:  “It seems as if you are very discouraged with P.T.” or “It sounds as if you are quite concerned about whether you made a right decision”.  Avoid a response like, “I know how you feel”.  Such a response makes the senior unsure about your truly understanding of him/her.  It is a rote response and is not based on a genuine understanding of his/her current feelings.

Talk on the senior’s level of understanding and adjust your tone of voice to his or hers.  For example, if you use a declarative, harsh tone of voice, it will seem as if you are telling the patient what he/she thinks and how he/she feels.  That is not an example of reflecting his/her feelings.  Using language that he/she does not understand will convey a lack of respect, regardless of the accuracy of your interpretation.

Evaluate the elderly person’s true feelings.  Sometimes he/she is not ready to admit certain feelings and needs time to deny them.

Reflect the senior’s feelings frequently for correction, disapproval or approval.  Remain open to his/her response.  A patient who is free to correct you moves on to a higher level of self-understanding.  If he/she cannot refute your reflection, he/she then can build up defenses.  This leads to withdrawal, thereby defeating the primary purpose of the relationship.  Some examples of how to begin your reflections are:  “If I understand you correctly, you feel…..” or you might say, “Is that right?”.

Respond actively and frequently enough to the senior, without interrupting him/her.  This indicates that you are focusing on his/her speech and feelings.

The ultimate purpose of the empathetic response is to convey to the person a depth of understanding about him/her and his/her predicament so that he/she can expand and clarify his/her understanding of self and others.  The patient receives relief from loneliness and overcomes feelings of isolation and aloneness with his problems.  Your willingness to understand how the senior feels about his or her world implies that his/her point of view is valuable.  Also, the focus of evaluation is within the patient, so that he becomes less dependent on the opinions of others and grows to value him or herself.  Empathetic understanding is not a passive process.  It will not happen without effort.  You must concentrate intensely on the person.  Intense concentration allows you little time to reflect on personal needs, values and ideals.  It prevents judgmental thoughts or behavior.

Improvement in patients’ conditions is correlated with empathetic responses, regardless of their diagnoses.  Not only are high empathetic levels correlated with improvement, but it is found that low levels of empathy contribute to increased disturbance in patients.  The lack of empathy displayed by nurses could, therefore, be hindering their patient’s recovery.

5. GOAL FORMULATION

A helping relationship differs from a social relationship.  In the helping relationship there is explicit formulation of goals.  You may have certain goals that you hope to accomplish, but the senior must actively participate with you in setting mutual goals.  As the relationship progresses, new problems or concerns will be identified and new goals will have to be set.  The relationship is structured in that you share with the patient what he or she can expect.  You then listen to what the patient expects of you.  Together you determine the course of the relationship.  Intentions and expectations are verbally and nonverbally conveyed to each other.  Expectations will usually change as the relationship progresses.

General goals of the nurse-patient relationship include:

a.           Increasing the senior’s self-esteem and promoting a positive self-concept and sense of security.

b.          Decreasing the senior’s anxiety to a minimum.

c.          Providing a gratifying, positive experience.

d.          Assisting the senior in improving communication skills and in participating comfortably with others.

e.           Providing the opportunity for the person to grow emotionally.

f.            Helping the senior find meaning in his/her life situation.

g.          Maintaining and stimulating the person biologically, mentally, emotionally and socially.

h.          Gather data to gain in-depth assessment to provide individual care.

6. HUMOR

Intense interaction between two or more people cannot endure unless a sense of humor surfaces at times.  Humor is the ability to see the ludicrous or the incongruities of a situation, to be amused by one’s own imperfections or the whimsical aspects of life, to see the funny side of an otherwise serious situation.  Humor does not necessarily mean joking and teasing.  It does not involve the put-down of another and it does not always evoke laughter.  Humor may be expressed as a tiny smile that lingers or the mental chuckle that occurs when you are sober-faced.

The purposes of humor include:

·              Releasing tension, anxiety or hostility.

·              Cautiously distracting from sadness, crying or guilt.

·              Decreasing social distance.

·              Conveying a sense of empathy to another.

·              Expressing warmth and affection.

·              Encouraging learning or task accomplishment.

·              Denying painful feelings or a threatening situation.

The elderly patient often has experienced use of humor beneath those steely eyes and tight lips.  He may test you with a few dry statements to see if you are really alert and if you can make the cognitive connections he insinuates.  Too often these dry statements receive only a grunt in reply, or worse, they are ignored and the senior is labeled senile, confused or crazy.

If you do not respond to his humor, he/she loses emotional and social input and self-esteem.  Although underneath he/she may consider you his/her inferior – less educated, less experienced, less wise.  You lose when you cannot expand your mind with the humorous.  You dry up emotionally and you have lost an opportunity to learn, to mature and to enjoy.

The nurse patient relationship, according to research by Press Ganey Associates Inc., sets the tone of the care experience and has a powerful impact on patient satisfaction. Nurses spend the most time with patients. Patients see nurses’ interactions with others on the care team and draw conclusions about the hospital based on their observations. Also, nurses’ attitudes toward their work, their coworkers and the organization affect patient and family judgments of all the things they don’t see behind the scenes.

Without a positive nurse patient relationship, there cannot be patient and family satisfaction. And there cannot be an environment that supports anxiety reduction and healing.

By analyzing and understanding the factors that have the greatest impact on overall patient satisfaction, you can AIM. You can focus your efforts and resources on improvements with the greatest potential to enhance the patient experience.

On the CAHPS survey, there are two global items: “Overall rating of hospital” and “likelihood of recommending hospital.” Based on 2007 CAHPS and Press Ganey Survey data, Press Ganey identified “Nurse Communication” as the factor with the greatest impact on patients’ overall ratings of their hospital experience. Survey items that focus on the nurse patient relationship drive patient ratings of their overall experience. Quality of communication iursing also has the highest impact on patients’ likelihood to recommend the hospital.

 

Patients and families want much more from nurses than competent clinical care.

Patients and families count ourses to keep them informed, to connect them to their physicians and other caregivers, to listen to them, to ease their anxiety, and to protect and watch over them during their healthcare experience. Because of these high expectations of nurses, it’s no wonder that nursing performance, and more specifically, the nurse patient relationship, is so central to patient satisfaction and a quality patient experience.

Yet, in strategies to achieve service excellence, while some nurses are enthusiastic, committed and supportive, many express concerns and resistance.

·              Some nurses feel insulted. They think, “I’m a nursing professional! I’m with people when they’re sick and dying, and now I’m being told to smile more?!?” Or they feel judged, “How dare anyone imply that I don’t care!?!”

·              Some nurses feel resentful. They think, “When this organization removes the obstacles that make my life difficult, I’ll smile more!”

·              And other nurses feel cynical. They think, “This IS important, but it won’t stick. This too shall pass like other things we’ve tried to do here.”

There’s more than one grain of truth in each of these sentiments.

·              Often service improvement strategies in health care have emphasized cosmetic aspects of the service relationships. Nurses are keenly aware of working with people who are emotionally drained and emotionally charged, and facing traumatic life circumstances. Making them happy hardly seems like a relevant goal, and nurses perceive it as superficial and discounting of the important work they do.

·              Resistance to raised service standards is also understandable wheurses perceive leaders as doing too little to remove obstacles to provide excellent care and service. Broken equipment, linen shortages, short staffing, inadequate support in the face of disrespectful doctors – all of these and more obstacles cause nurses to say, “Don’t pin patient dissatisfaction on us! We don’t have the support we need to provide the care we WANT to provide.”

·              Cynical nurses who are very dedicated to patients and families sound their frustration over past initiatives that raised their hopes but then fizzled due to lack of follow-through by the organization’s leaders.

Leaders also need to run interference. They need to remove the barriers and create the conditions that make it possible for nurses to serve their patients and families with diligent and compassionate care.

And finally, to engage nurses’ hearts and minds in strengthening their communication with patients and families, leaders need to ensure follow-up and follow-through. Quick fix approaches might be compelling but not sustainable. Strengthening nurses’ skills and the hard work of supporting APPLICATION of these skills to the nurse patient relationship in their everyday work requires a long-term investment of time and energy… or cynicism is the predictable result.

Help Nurses Make Their Caring Felt

Nurses care, but patients and families may not FEEL their caring.

Nurses are so swamped. Their multiple responsibilities breed task-orientation, not people-orientation. Then, seeing nurses focus on the tasks and activities of their jobs, patients and families wonder, “Where has all the caring gone?”

The caring is still there, but it might as well not be if patients and families don’t see or feel it. That’s why there’s a crying need today to help nurses speak the language of caring so that their caring reaches the people they serve. In everyday routines, there are so many opportunities to make their caring felt and ease their patients’ anxiety. For instance, when one nurse’s shift is ending and another nurse is taking over the patient’s care, the first nurse can ease the transition for the patient by speaking the language of caring

 

Caring Framework for Nursing Practice

Dr. Jean Watson in “The Theory of Transpersonal Caring” said,

·              Caring is central to the nursing role and its mission as a distinct profession.

·              Caring is often the measure by which patients evaluate their “cure-dominated” experience.

 

Highlight the Meaning in the Nurse’s Work

Dr. Jean Watson also said, “Caring is transpersonal iature, involving the one caring as well as the one being cared for.” With nurses so fraught with multiple demands and pressures, many lose touch with their caring mission. This is a sad shame. It leads to fatigue and disillusionment. Some remain in the job and these effects show in their relationships (or lack of relationships) with patients, families and coworkers. Others leave in a cloud of cynicism and grief that may be personally damaging to the nurse and also discouraging to future prospects for nursing careers.

Nurse Managers (also fraught with an overload of responsibilities) need to adopt as a central priority helping their nurses rekindle and sustain their passion for the work…. 

 

Services That Enhance the Nurse Patient Relationship by Wendy Leebov and Associates will help your nurses:

·              Renew their sense of caring mission and help them sustain their passion for the work

·              Speak the language of caring in the full range of emotionally demanding situations they handle daily

·              Score highly on patient satisfaction survey items that focus on communication in the nurse patient relationship and correlate highly with patient ratings of their overall experience with your organization.

Long-Term Strategies

·              Strengthen Your Care Team’s “Empathy” Competency

·              First Touch – A Revolutionary Strategy that Nets Results 

·              Soul-full Work: Tap the Power of Personal Stories for Nurse Recognition and Renewal

Speeches

·              Care with Compassion: The Power of ONE

·              Good to Great in Everyday Encounters

·              Dealing with Difficult-for-me People

·              Soulful Work

Workshops for Nurses

·              Good-to-Great in Everyday Encounters

·              Caring Communication

·              Dealing with the Difficult-for-Me Patient

·              Stressbusters Series

·              Peer Coach Training

 

Practice Standards set out requirements related to specific aspects of nurses’ practice. They link with other standards, policies and bylaws of the College of Licensed Practical Nurses of British Columbia, the College of Registered Nurses of British Columbia and the College of Registered Psychiatric Nurses of British Columbia, and all legislation relevant to nursing practice.

The nurse-client relationship is the foundation of nursing practice across all populations and cultures and in all practice settings. It is therapeutic and focuses on the needs of the client.¹ It is based on trust, respect and professional intimacy,² and it requires the appropriate use of authority. The nurse-client relationship is conducted within boundaries that separate professional and therapeutic behaviour from non-professional and non-therapeutic behaviour. A client’s dignity, autonomy and privacy are kept safe within the nurse-client relationship.

Within the nurse-client relationship, the client is often vulnerable because the nurse has more power than the client. The nurse has influence, access to information, and specialized knowledge and skills. Nurses have the competencies to develop a therapeutic relationship and set appropriate boundaries with their clients. Nurses who put their personal needs ahead of their clients’ needs misuse their power.

The nurse who violates a boundary can harm both the nurse-client relationship and the client. A nurse may violate a boundary in terms of behaviour related to favouritism, physical contact, friendship, socializing, gifts, dating, intimacy, disclosure, chastising and coercion.

Some boundaries are clear cut. Others are not so clear and require the nurse to use professional judgment. This is true particularly in small communities³ where nurses may have both a personal and a professional role. Employers that provide education, supervision and support related to boundary issues will help staff recognize and resolve problems in the early stages.

PRINCIPLES

1.          Nurses use professional judgment to determine the appropriate boundaries of a therapeutic relationship with each client. The nurse — not the client — is always responsible for establishing and maintaining boundaries.

2.          Nurses are responsible for beginning, maintaining and ending a relationship with a client in a way that ensures the client’s needs are first.

3.          Nurses do not enter into a friendship or a romantic relationship with clients.

4.          Nurses do not enter into sexual relations with clients ⁴.

5.          Nurses are careful about socializing with clients and former clients, especially when the client or former client is vulnerable or may require ongoing care.

6.          Nurses maintain the same boundaries with the client’s family and friends as with the client.

7.          Nurses help colleagues to maintain professional boundaries and report evidence of boundary violations to the appropriate person.

8.          At times, a nurse must care for clients who are family or friends⁵. When possible, overall responsibility for care is transferred to another health care provider.

9.          At times, a nurse may want to provide some care for family or friends. This situation requires caution, discussion of boundaries and the dual role⁶ with everyone affected and careful consideration of alternatives.

10.      Nurses in a dual role make it clear to clients when they are acting in a professional capacity and when they are acting in a personal capacity.

11.      Nurses have access to privileged and confidential information, but never use this information to the disadvantage of clients or to their own personal advantage.

12.      Nurses disclose a limited amount of information about themselves only after they determine it may help to meet the therapeutic needs of the client.

13.      Nurses may touch or hug a client with a supportive and therapeutic intent and with the implicit or explicit consent of the client.

14.      Nurses do not communicate with or about clients in ways that may be perceived as demeaning, seductive, insulting, disrespectful, or humiliating. This is unacceptable behaviour.

15.      Nurses do not engage in any activity that results in inappropriate financial or personal benefit to themselves or loss to the client. Inappropriate behaviour includes neglect and/or verbal, physical, sexual, emotional and financial abuse.

16.      Nurses do not act as representatives for clients under powers of attorney or representation agreements.

17.      Generally, nurses do not exchange gifts with clients. Where it has therapeutic intent, a group of nurses may give or receive a token gift. Nurses return or redirect any significant gift. Nurses do not accept a bequest from a client.

 

APPLYING THE PRINCIPLES TO PRACTICE

Be transparent, therapeutic and ethical with all your clients and former clients. When the issues are complex and boundaries are not clear, discuss your concerns with a knowledgeable and trusted colleague.

Disclose your personal information only with a therapeutic intent, such as to develop trust and establish a rapport with a client. Focus on the client’s needs. Do not disclose intimate details or give long descriptions of your personal experience.

Recognize that if you accept clients as personal contacts on social media sites, you may be crossing a boundary. You may also breach client privacy and confidentiality. Do not discuss clients (even anonymously or indirectly) or share client pictures on social media sites or in any public forum.

Understand that nurses who work and live in the same community often have a dual role. If you have a personal relationship with a client or former client, be clear about when you are acting in a personal relationship and when you are acting in a professional relationship. Explain your commitment to confidentiality and what the client can expect of you as a nurse. Consider the difference between being friendly and being friends.

Be cautious in forming a personal relationship with a former client. Consider the amount of time that has passed since the professional relationship ended; how mature and vulnerable the former client is; whether the former client has any impaired decision-making ability; the nature, intensity, and duration of the nursing care that was provided; and whether the client is likely to require your care again.

Before touching or hugging a client, determine whether such contact would be appropriate, supportive and welcome.

Be careful about accepting a token gift from a client. Consider why the client has offered the gift to you, and the value and appropriateness of the gift. When you refuse a gift, explain why in a sensitive manner. Discuss ways the gift could be redirected.

If you are a nurse administrator, educator or researcher, consider how these principles apply to your relationships with staff, students and research participants.

Seek impartial help to clarify the boundaries of a therapeutic relationship if you become aware of any of the following behaviour in yourself or a colleague:

1.          The nurse’s behaviour is not consistent with CRNBC Standards of Practice.

2.          There is conflict between the nurse’s needs and the client’s needs, and the nurse is not demonstrating that the client’s needs are the priority.

3.          Aspects of the nurse’s relationship with the client are hidden from others.

4.          The nurse does not want other nurses to have the same relationship with the client.

5.          The nurse is using the client to meet the nurse’s personal needs for status, social support or financial gain.

6.          The nurse is preoccupied with the client.

7.          The nurse is giving preferential care or time to the client.

8.          The nurse is unclear about when the relationship with a client is professional and when it is personal.

9.          The nurse has entered into a personal relationship with a client before taking all the appropriate steps to end the professional relationship.

 

FOOTNOTES

1.          Client: An individual, family group, population or entire community that requires nursing expertise. In some clinical settings, the client may be referred to as a patient or resident. In research, the client may be referred to as a participant.

2.          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.

3.          Small communities include rural and remote communities and small, discrete communities within urban centres, for example, religious, gay or military communities.

4.          The Health Professions Act, Section 26 states that professional misconduct includes sexual misconduct, unethical conduct, infamous conduct and conduct unbecoming a member of a health profession. CRNBC Bylaws define sexual misconduct as professional misconduct involving sexual intercourse or other forms of physical sexual relations between a registrant and a patient, touching, of a sexual nature, of a patient by a registrant, or behaviour or remarks of a sexual nature by a registrant towards a patient; but does not include touching, behaviour and remarks by a registrant towards a patient that are of a clinical nature appropriate to the service being provided.

5.          For example, in an emergency or in a small community.

6.         A nurse in a dual role has both a personal and professional relationship with a client. While not desirable, a dual role is often unavoidable, particularly in small communities.