Thank you to the College of Registered Nurses of British Columbia for permission to adapt their case study.
Right from the beginning, Nico feels a little put off by his new dialysis client, Mr. Stedman. Nico’s clients have always responded well to his cheerful and upbeat manner, but Mr. Stedman does not.
He's non-communicative and unsmiling, responding to Nico’s questions with monotone one-word answers. For the first few weeks, Nico works at building a rapport with Mr. Stedman but it seems his efforts are ignored. His attempts at client teaching also seem ineffective — Mr. Stedman makes few changes to his lifestyle or diet. Although Mr. Stedman begins to warm to other staff, after a month, Nico still feels unable to connect with him. Feeling powerless, Nico rationalizes that he cannot do anything else and Mr. Stedman won’t change. He begins to spend less time with Mr. Stedman, finding ways to minimize contact and conversation.
Today, as usual, Nico leaves Mr. Stedman waiting after his treatment. When he does come to disconnect him, he begins without a word, removing the tape and needle and applying pressure. As he does this, he sees his co-worker, Melissa, watching.
After Mr. Stedman leaves, Melissa stops Nico in the hall and asks, “Can I talk to you for a few seconds?” She continues, “Is everything alright? You don’t seem yourself with that client.” Nico responds, “That guy rubs me the wrong way. I’ve given up trying to get through to him.”
Melissa looks at Nico with surprise, “Mr. Stedman? He’s a sweet old guy!” Nico replies “To you maybe! I’ve tried everything. He doesn’t talk to me or listen to me. He has to make an effort too.” Melissa responds thoughtfully, “It’s not always easy, but building a relationship is up to us - not the client...” Nico interrupts, “Look, could we talk about this later?”
Nico stews about Melissa’s remarks during the rest of his shift. At first, he feels defensive. After all, Mr. Stedman doesn’t take care of himself and doesn’t talk during his visits. Nico knows he really tried to build a relationship with Mr. Stedman, but didn’t get a positive response. What else could he do?
Nico begins to look at his practice more reflectively. He admits that while he knows Mr. Stedman's physical history, he doesn't know much about his perspective or experience with his chronic disease. He realizes he needs to learn more from Mr. Stedman and find a different way to connect with him.
It's the first time he's been unable to build a rapport with a client, and he's let his focus drift to his own emotional response, rather than remain on Mr. Stedman and his best interests. In reflection, he recognizes that he has been avoiding Mr. Stedman, delaying his care as long as he can and given up trying to provide any patient teaching. He's not involved enough to have a helpful or therapeutic relationship with Mr. Stedman.
Nico approaches Melissa at the end of the shift. "I'd like to talk about Mr. Stedman. I know I need to try a different approach and would appreciate any suggestions."
Professional Boundaries for Registered Nurses: Guidelines for the Nurse-Client Relationship outline the expectations for appropriate professional relationships with clients. A therapeutic nurse-client relationship is the foundation of nursing practice as supported with Practice Standard 3.3: the nurse ensures that their relationships with clients are therapeutic and professional. It is based on trust and focused on the needs of the client. Within this relationship, a client's dignity, autonomy and privacy are kept safe.
Nico is responsible for establishing a relationship with Mr. Stedman in a way that ensures Mr. Stedman's needs are his primary concern. Nico needs to reflect on how his own values and beliefs are shaping the way he thinks about and provides care to Mr. Stedman. He is also responsible for establishing and maintaining appropriate boundaries in his therapeutic relationship with Mr. Stedman.
Boundaries can be viewed as a continuum of behavior. At one end is the zone of over-involvement and at the other, under-involvement. The zone of helpfulness or therapeutic relationship is in the middle. Client harm can occur at either end of the continuum. Under involvement includes distancing from the client, disinterest in the client or their care and neglect. When Nico becomes under-involved with Mr. Stedman, their relationship is no longer therapeutic.
Under our Practice Standards 5.6 (Self-Regulation) nurses must regularly assess their practice and take the necessary steps to improve personal competence. By reflecting on his practice and identifying ways to improve, Nico is taking steps toward meeting this standard and participating in quality assurance.