This standard applies to LPNs, NPs, RNs, and RPNs.
Practice Standards set out requirements related to specific aspects of nurses' practice. They link with other standards, policies and bylaws of the BC College of Nurses and Midwives, and all legislation relevant to nursing practice.
The
nurse1-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.2 It is based on trust, respect and professional
intimacy,3 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
communities4 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.
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2.
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Nurses are responsible for beginning, maintaining and ending a relationship with a client in a way that ensures the client’s needs are first.
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3.
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Nurses do not enter into a friendship or a romantic relationship with clients.
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4.
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Nurses do not enter into sexual relations with
clients,5 with or without consent.
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5.
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Nurses are careful about socializing with clients and former clients, especially when the client or former client is vulnerable or may require ongoing care.
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6.
| Nurses maintain the same boundaries with the client’s family and friends as with the client.
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7.
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Nurses help colleagues to maintain professional boundaries and report evidence of boundary violations to the appropriate person.
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8.
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At times, a nurse must care for clients who are family or
friends6. When possible, overall responsibility for care is transferred to another health care provider. Nurses must also be aware where legislation specifically prohibits a nurse from providing care or services to friends or family members.
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9.
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At times, a nurse may want to provide some care for family or friends. This situation requires caution, discussion of boundaries and the dual
role7 with everyone affected and careful consideration of alternatives.
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10.
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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.
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11.
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Nurses have access to privileged and confidential information, but never use this information to the disadvantage of clients or to their own personal advantage.
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12.
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Nurses disclose a limited amount of information about themselves only after they determine it may help to meet the therapeutic needs of the client.
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13.
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Nurses may touch or hug a client with a supportive and therapeutic intent and with the implicit or explicit consent of the client.
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14.
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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.
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15.
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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.
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16.
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Nurses do not act as representatives for clients under powers of attorney or representation agreements.
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17.
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Nurses do not act as a substitute decision maker under Part 3 of the Health Care (Consent) and Care Facility (Admission) Act when they:
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a.
| are also a "manager" (per the definition within the Act) responsible for the operation of the facility, or
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b.
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are responsible for admissions to a care facility.
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18.
| 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.
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Applying the principles to practice
Ensure you review legislation relevant to the nurse-client relationship, as some laws may affect the roles that nurses can assume.
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.
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.
Nurses who work and live in the same community often have a dual role. Ensure that the applicable legislation does not prohibit you from acting in a nursing role and a personal role at the same time. 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:
a.
| The nurse’s behaviour is not consistent with BCCNM Standards of Practice.
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b.
| 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.
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c.
| Aspects of the nurse’s relationship with the client are hidden from others.
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| d. | The nurse does not want other nurses to have the same relationship with the client.
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| e. | The nurse is using the client to meet the nurse’s personal needs for status, social support or financial gain.
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| f. | The nurse is preoccupied with the client.
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| g. | The nurse is giving preferential care or time to the client.
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h.
| The nurse is unclear about when the relationship with a client is professional and when it is personal.
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i.
| The nurse has entered into a personal relationship with a client before taking all the appropriate steps to end the professional relationship.
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1.
| “Nurse” refers to all BCCNM registrants, including: licensed practical nurses, nurse practitioners, registered nurses, registered psychiatric nurses, licensed graduate nurses, employed student nurses, and employed student psychiatric nurses.
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| 2. | "Clients" include individuals, families, groups, populations or entire communities receiving nursing care or services from a nurse.
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3.
| 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. College of Nurses of Ontario. (2006). Therapeutic nurse-client relationship. Toronto: Author.
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4.
| Small communities include rural and remote communities and small, discrete communities within urban centres.
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5.
| 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. BCCNM 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.
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6.
| For example, in an emergency or in a small community.
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7.
| 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. Note that this may be prohibited in certain circumstances.
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