Standards of Practice

Meet Annette

Annette, registered nurse (RN) works in a rehabilitation centre for clients with spinal cord injuries. She enjoys her work and feels like she makes a difference in the lives of the people she works with. Steve is a 48-year-old client who is a paraplegic as a result of a car accident. Steve’s wife Leanne has been a great source of support and has rarely left his side since the accident. Annette has become very friendly with Leanne; they have children the same age, enjoy similar activities and have a lot in common.

A few weeks after Steve is discharged home, Leanne sends Annette a Facebook message asking to get together with her and Steve for coffee.

What Should Annette Do?

Reflecting on the 2019 RN Standards of Practice

Annette needs to consider if meeting Leanne and Steve for coffee in a social context could violate professional boundaries.  Professional boundaries are defining lines which separate the therapeutic behaviour of RNs from any behaviour which, well-intentioned or not, could reduce the benefit of care to clients.

Staying within appropriate boundaries promotes safe and effective care that meets clients’ needs. It may be acceptable in some instances for an RN to engage in a social relationship with a former client and/or their family. It may be acceptable for an RN to socialize with a client outside of the workplace if for example, the RN provides care to a client for only a few days and then is not expected to provide care for the client again.

Annette will need to ensure she is meeting the 2019 Standards of Practice for Registered Nurses. Specifically, how will Annette meet the following indicator in Standard 3?

• 3.3 initiates, maintains and concludes the therapeutic nurse‐client relationship.

In thinking of the standards of practice, Annette will need to consider the following before establishing a friendship with Leanne and Steve:

• amount of time since the end of the professional relationship with Steve and Leanne
• the amount of emotional stress Steve was experiencing during the therapeutic relationship
• the nature, intensity and duration of care
• the potential impact on Steve and Leanne’s future experiences with the health care system. For example, would they trust other health care providers or believe they would need to travel elsewhere for treatment if the social relationship ended poorly?
• the likelihood of Steve requiring future care from the Annette
• the degree to which Steve has developed an emotional dependency on Annette.

Next Steps

Annette considers these factors. Using the standards of practice as a guide, she confirms that when Steve was hospitalized, the relationship between the three of them was strictly professional. She also notes that a period of time has elapsed since Steve was discharged, which means that a personal relationship had not started when Steve was her client.

Once Annette has confirmed the relationship was professional, she now needs to consider how long Steve was a client, the emotional support Steve required during their therapeutic relationship, and the likelihood of Steve requiring future care from Annette.

The care Annette provided to Steve was focused on his physical, emotional, and psychological needs. For example, it focused not only on his spinal cord injury but also his loss of independence and his loss of income. He was a client of Annette’s for six months and there is a possibility Steve could be re-admitted and may require ongoing nursing care.

Based on a review of these factors, Annette determines it may not be appropriate to see Leanne and Steve in a social relationship because:

• There is a possibility she will have an ongoing professional relationship with Leanne and Steve. If she establishes this personal relationship, she could be at risk of crossing professional boundaries.
• Therapeutic relationships with an emotional and psychological component can create an imbalance in power and can create a potential dependency on the RN.

Annette feels bad but she needs to ensure she is meeting her standards of practice. Annette explains her professional accountability to Leanne and Steve and declines their invitation for coffee. Although it didn’t feel the best declining the invitation, Annette feels confident that she has maintained professional boundaries and will be able to provide the best care possible to Steve, Leanne and other clients in the community in the future.

To know more about professional boundaries, please refer to the Standards for the Nurse-Client Relationship.

For more information on Client-Centered Practice, continue to explore Standard 3 within the 2019 Standards of Practice for Registered Nurses. If you have any questions in meeting this standard of practice, please contact a Nurse Consultant at practiceconsultation@nanb.nb.ca .

Karen, registered nurse (RN) works in long term care. She has become close to Esther, a client who recently celebrated her 95th birthday. During the celebration, Karen asked Esther’s daughter if she could take a picture with her cell phone. Esther’s daughter said that would be fine.

Later that day, Karen posted the picture to her Facebook with a caption “so happy I work with special people like this”. Karen’s profile identifies her as an RN who works at Shady Lane Nursing Home.

Karen breached Standard 3, indicator 3.4: upholds and protects clients’ privacy and confidentiality in all forms of communication included but not limited to e-records, verbal, written, social media by using her personal cell phone to photograph a client and then posting the client’s picture on her Facebook account which identifies where she works.

Refer to the Standards of Practice document to identify other standard 3 indicators Karen violated.

3.3. initiates, maintains and concludes the therapeutic nurse-client relationship. Perhaps you identified others.

Know the social media policies at your workplace. Also, check out the Practice Guideline: Social Media.

For more information on Client-Centered Practice, continue to explore Standard 3 within the 2019 Standards of Practice for Registered Nurses. If you have any questions in meeting this standard of practice, please contact a Nurse Consultant at practiceconsultation@nanb.nb.ca .

Lisa, a graduate nurse (GN), receives her patient assignment for her shift.  On report Lisa hears about an Indigenous client on the unit who is one day post-op from a lower leg amputation.  The night registered nurse’s (RN) report indicated the client is lazy, non-compliant, and deserves this outcome.  Lisa immediately wants to advocate for compassionate and culturally safe care for the client, but because she is new to the unit and a GN she feels powerless.

As the day progresses, Lisa cannot get this experience out of her mind and feels it is impacting the nursing care she is able to provide.  She is unsure how her colleagues feel about what happened and if they share the same biases.  Lisa does not feel safe sharing her feelings about the experience or advocating for culturally safe care for the client.

Question: How can Lisa meet standard 3, indicator 3.9? (3.9 respects diversity and promotes cultural competence and a culturally safe environment for clients and members of the health care team)

Answer: Lisa, as a GN, is responsible to adhere to the Code of Ethics for Registered Nurses and therefore to advocate for her client and herself.  It is important that she addresses this situation. If Lisa isn’t comfortable to speak up by herself, she could consult her Nurse Manager/Supervisor for guidance. Lisa could use the following nursing values and ethical responsibilities to speak with the RN in question and other colleagues:

• Providing safe, compassionate, competent and ethical care
  • “Nurses question, intervene, report and address unsafe, non-compassionate, unethical or incompetent practice or conditions that interfere with their ability to provide safe, compassionate, competent and ethical care; and they support those who do the same” (CNA, 2017, p. 8).
  • Nurses are to reflect on and acknowledge their own implicit biases when working with clients of diverse cultures and cultural backgrounds. Implicit biases are often unintentional but are frequently the cause of insensitive attitudes and behaviors which, negatively affect the nurse-client relationship (Narayana, 2019).
• Honoring Dignity
  • “Nurses intervene, and report when necessary, when others fail to respect the dignity of a person they are caring for or a colleague (including students), recognizing that to be silent and passive is to condone the behavior. They speak up, facilitate conversation and adjudicate disputes, as appropriate/required” (CNA, 2017, p. 12)
• Promoting Justice
  • “Nurses do not discriminate on the basis of a person’s race, ethnicity, culture, political and spiritual beliefs, social or marital status, gender, gender identity, gender expression, sexual orientation, age, health status, place of origin, lifestyle, mental or physical ability, socio-economic status, or any other attribute” (CNA, 2017, p. 15)
  • “Nurses respect the special history and interests of Indigenous Peoples as articulated in the Truth and Reconciliation Commission of Canada’s (TRC) Calls to Action (2012)” (CNA, 2017, p. 14)
  • “Nurses refrain from judging, labelling, stigmatizing and humiliating behaviors toward persons receiving care or toward other health-care providers, students and each other” (CNA, 2017, p. 14)

What other nursing values and ethical responsibilities from the Code of Ethics you think Lisa could use to address this situation?

For more information on Client-Centered Practice, continue to explore Standard 3 within the 2019 Standards of Practice for Registered Nurses. If you have any questions in meeting this standard of practice, please contact a Nurse Consultant at practiceconsultation@nanb.nb.ca

NANB gratefully acknowledges the contribution of Bev Gaudet, Shelly Francis and Aaron Hatty in the development and revision of this case study.

• Cultural Safety

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