Standards in Focus

Therapeutic Relationships: Under-Involvement in Client Care

June 27, 2022

This edition of Standards in Focus highlights the Standards of Practice and Conduct that speak to therapeutic relationships, specifically under-involvement in client care, and provides you with the opportunity to reflect on how to apply the Standards in your practice.

Several Standards speak to expectations related to therapeutic relationships. Category two (II) of the Standards is focused on competent practice and states that licensed practical nurses are responsible for safe, compassionate, and ethical nursing practice. Standards related to therapeutic relationships state the following.

As an LPN, you must:

Demonstrate the knowledge, skill, and professional and clinical judgment necessary for practising in a safe, competent, compassionate, and ethical manner. (Standard 15)
Identify potential and actual risk and take action to safeguard clients. (Standard 23)

Category three (III) of the Standards is focused on therapeutic relationships and states that licensed practical nurses establish therapeutic relationships and maintain professional boundaries at all times. Standards related to therapeutic relationships state the following.

As an LPN, you must:

Establish, maintain, and appropriately end professional, therapeutic relationships with clients and their families in consideration that the nurse – not the client or family – is responsible for establishing and maintaining professional boundaries. (Standard 30)
Use a wide range of effective communication strategies and interpersonal skills to appropriately establish, maintain, re-establish, and end the therapeutic relationship. (Standard 31)
Protect the client’s dignity, autonomy, and privacy irrespective of the context or duration of the relationship. (Standard 32)
Demonstrate trust and respect for the client, by displaying caring actions and caring attitudes. (Standard 33)
Ensure that the client’s therapeutic needs remain the focus of the therapeutic relationship. (Standard 34)
Protect the client from harm by ensuring that abuse is prevented or stopped and reported. (Standard 35)

Category four (IV) of the Standards is focused on client-centred practice and states that licensed practical nurses provide nursing services that are client centred. Standards related to therapeutic relationships state the following.

As an LPN, you must:

Advocate for your clients by actively supporting, protecting, and safeguarding their rights and interests. (Standard 37)
When engaging in practical nursing in a clinical practice setting, provide nursing care that includes:
- an assessment to determine the needs and circumstances of the client (Standard 38. a.)
- a care or treatment plan developed with the client or their representative and any other person who the client wishes to involve, which considers the client’s needs, circumstances, preferences, values, abilities, and culture (Standard 38. b.)
- an evaluation of the outcomes of the care or treatment plan, and the modification or discontinuance of the care or treatment plan as required, and as discussed with the client or their representative (Standard 38. c.)
- sufficient and timely communication with the client or their representative that considers the client’s needs, circumstances, culture, understanding and use of health information and enables the client or their representative to make informed decisions about the client’s health care (Standard 38. d.)
- a referral of the client to another nurse or health care professional when appropriate (Standard 38. e.)

The entry-level and full competencies for the profession also lay out the expectations for the competencies related to therapeutic relationships. ^{2, 3} Examples of competency statements include:

Differentiates between the attributes of therapeutic relationships and non-therapeutic relationships.
Establishes, maintains, and appropriately concludes therapeutic relationships that are goal-oriented and client-centred.
Establishes caring relationships that maintain client dignity during the course of care.
Maintains therapeutic relationships that are compassionate and culturally safe.
Establishes and maintains respect, empathy, trust, and compassion in interactions with clients.
Applies conflict management and resolution skills when necessary.
Acquires and applies theoretical knowledge related to views on caring, including the moral and ethical basis of responsive nurse-client relationships and the challenges of caring (e.g., human caring model, task-oriented biomedical model, institutional demands).

To read more on the competencies related to therapeutic nurse-client relationships, please see here.

Therapeutic Relationships in Nursing Practice

A therapeutic relationship remains within the therapeutic zone on the continuum of professional behaviour. ⁴ The continuum of professional behaviour goes from too little health care provider involvement (i.e., under-involvement) to too much health care provider involvement (i.e., over-involvement). ⁶ A therapeutic relationship’s zone of helpfulness is in the middle. Client harm can occur at either end of the continuum. ^{5, 8}

The nurse is responsible for ensuring that their relationship with each client is a professional, therapeutic relationship. A therapeutic relationship is one that:

is established and maintained to meet the client’s needs;
remains focused on the client’s therapeutic needs;
optimizes the client’s health and health outcomes; and,
provides the foundations for safe, competent, ethical, and compassionate nursing care.⁴

Under-involvement and over-involvement can become professional boundary crossings, extend to professional boundary violations, and be considered neglect or abuse.⁷ Professional boundaries are the borders or limits that a nurse sets to protect themselves and their clients from developing unprofessional, unethical, confusing, or conflicting relationships.⁵ Boundaries are required when developing therapeutic relationships with clients due to the personal nature of nursing care, and appropriate professional boundaries create a zone that allows for a safe and effective relationship between the nurse and the client.⁵ When a nurse becomes under-involved or over-involved with a client, the goals of the therapeutic relationship are put at risk, as is the client’s health and well-being. ⁴

Specifically, under-involvement refers to disinterest, avoidance, or neglect of clients and their needs.⁴ Under-involvement, or disengagement, can occur when an LPN finds themselves withdrawing from clients when the client exhibits undesirable behaviours or due to the intensity of the client’s responses.^{6, 7} An LPN may find themselves disengaging with a client when the client is:

near death, and the LPN is not comfortable watching the client die,
frequently calling the nurse for assistance,
sexually inappropriate,
hostile,
depressed, or
anxious.⁶

Under-involvement, or disengagement, may put the client at risk because their care needs may not be met.⁴ Under-involvement in client care can look like:

delaying care or treatment (e.g., waiting to answer a call bell or delaying a needed medication unnecessarily);
taking shortcuts in a client’s care (e.g., not providing daily hygiene, skipping a dressing change);
blaming a client for lack of progress;
being rough when providing care;
using disrespectful, demeaning, insulting, or humiliating language or tone;
inadequately draping a client during a procedure;
withdrawing from or avoiding a client so that it interferes with meeting care needs (e.g., purposely changing assignment because the nurse had the client yesterday or avoiding answering the client’s call bell); or,
withholding information that a client needs to make an informed decision.^{5, 6}

In cases of under-involvement, the nurse-client relationship can be affected on two levels:

By avoiding a client, a nurse may focus on the tasks associated with providing minimal care rather than dealing with the issues that are making the nurse feel uncomfortable (e.g., the client exhibiting undesirable behaviours or having intense responses).
Avoidance can raise the potential for substandard care (e.g., the nurse fails to recognize physical or psychosocial needs that should be addressed). ⁷

When a nurse avoids a client, they put their own needs ahead of the client’s. ⁷ As a result, a nurse under-involved in client care may appear unempathetic, neglectful, uncaring, rude, or dismissive. ⁸ Avoidance of clients can lead to neglect, which is a boundary violation. ^{4, 7} Neglect is an example of harmful under-involvement in client care and is considered an extreme boundary violation. ^{4, 7} Neglect occurs when a nurse fails to meet the basic needs of a client who cannot meet the need themselves. ⁴ Abuse or neglect of a client may result in CLPNM investigation, a Protection for Persons in Care Act investigation, and/or criminal charges. ⁴

Examples of client neglect may include:

Withholding or failing to provide minimally adequate care;
Withholding the necessities of life such as clothing, food, fluid, required aids, equipment, and medication;
Withholding communication;
Confining, isolating, or ignoring the client; or,
Denying the client privileges. ^{4, 7, 9}

Note that withholding food or other treatments is not neglect when honouring the client’s wishes for end-of-life treatment after a comprehensive medical evaluation.⁴

To build and maintain effective therapeutic relationships, the nurse:

Develops mutual trust and respect between nurse and client;
Demonstrates empathy toward the client;
Acknowledges the client’s position of relative vulnerability in the relationship, resulting from the client’s reliance on the nurse for nursing care and the intimate nature of the services nurses provide; and,
Acknowledges, and is careful not to misuse, the nurse’s position of relative power in the relationship, resulting from the nurse’s specialized knowledge, influence within the care setting, and access to client personal information. ⁴

Additionally, when the client no longer requires nursing care from the nurse, the nurse has a responsibility to conclude the therapeutic relationship. Ending the professional nurse-client therapeutic relationship should be the final action performed by the nurse in any practice setting. ^{4, 6} Providing the client with information about the termination phase of the nurse-client relationship is deemed to be appropriate, professional, and ethical (e.g., the nurse informs the client that this is their last shift together, the client’s care is being transferred to another nurse, or the client is being discharged). ^{6, 9}

Ultimately, the nurse’s responsibility is to meet the needs of the client. If the nurse feels that they cannot meet the client’s needs and is experiencing any of the signs of under-involvement in the client’s care, the nurse must seek guidance or assistance from their colleagues, manager, or employer. ⁶

Nursing Practice Scenario

The following scenario shows how under-involvement in client care can lead to health risks for the client:

Ashley Jones, LPN works on a long-term care unit. She starts feeling uneasy when she learns about her client assignment for the next three shifts. Ashley’s client assignment includes Mrs. Smith, a 75-year-old female with a diagnosis of diabetes and cardiovascular disease. Ashley recalls that Mrs. Smith has always been rude and condescending to her in their previous interactions. Mrs. Smith requires hands-on help with her activities of daily living, and she needs to be turned every two hours while in bed. Having to care for this particular client fills Ashley with dread and increases her anxiety. To avoid the client’s undesirable behaviour, Ashley decides that she will provide the bare minimum of care in order to avoid Mrs. Smith as much as possible.

Ashley checks the client’s vital signs and blood glucose levels, gives the client her scheduled medications, and assigns washing, feeding, toileting, and bed turns to different health care aides on each shift. Ashley avoids answering Mrs. Smith’s call bell. She keeps her verbal communication with Mrs. Smith to a minimum, spending no more than 5-10 minutes with the client when she is in contact with her for vital signs monitoring, blood glucose checks, and medication administration.

Ashley’s disengagement from Mrs. Smith’s care results in her failure to monitor the client’s turning schedule. She also does not check in with the health care aides or the client about the client’s eating habits nor the condition of the client’s skin.

While Ashley is on her break during her last shift, Sally Peters, LPN, answers Mrs. Smith’s call bell and helps her with toileting. Sally notices that the client has a new stage 2 pressure ulcer on her right heel. Sally also notes that Mrs. Smith did not have pillows placed for pressure relief while in bed and that the turning schedule on the wall had no times or signatures recorded for the last 12 hours. Sally cleans Mrs. Smith’s heel, applies a dressing to the pressure ulcer, ensures the client has pillows placed for appropriate pressure relief and documents this situation in the client’s chart.

When Ashley returns from her break, Sally informs Ashley of her findings. Sally also discusses that she noted that Ashley appeared to be under-involved with Mrs. Smith. Sally suggests that if Ashley had been more engaged in the client’s care, the client may not have developed a pressure ulcer on her heel.

Ashley expresses to Sally that she finds it difficult to connect with and care for Mrs. Smith, but that she also feels awful about the client developing a pressure ulcer. Sally advises Ashley to speak with the manager about this situation and about her feelings related to caring for Mrs. Smith in hopes of finding a reasonable solution.

Ashley’s behaviour in the practice scenario is an example of a nurse breaching several of the Standards of Practice and Conduct. Standards 15 and 23 speak to expectations that the nurse must practice safely, competently, compassionately, and ethically in order to safeguard clients from risk and harm. ¹ Furthermore, Standards 37 and 38 a. to e. refer to expectations related to nurses providing nursing care that is client-centred and supportive of clients’ rights and interests. ¹ These Standards also indicate that nurses must engage in client-centred practice that uses the nursing process (i.e., assessment, diagnosis, planning, intervention, and evaluation), sufficient and timely communication, and appropriate referral of the client to other health care professionals to meet the needs of clients. ¹ Finally, Standards 30-35 refer to expectations that nurses must establish, maintain, and end therapeutic relationships with clients. ¹ Nurses must demonstrate respectful behaviour and display caring attitudes/actions towards clients, and they must protect clients from harm and prevent abuse (including neglect) in client care. ¹

In the practice scenario, Ashley failed to show competence in relation to delivering safe, compassionate, and ethical care to Mrs. Smith when she did not take the time to assess, identify, or address potential and actual risks to the client’s well-being (i.e., she did not assess or confirm the bed turning schedule over the course of her shifts). Ashley also breached the Standards when she failed to establish and maintain the therapeutic relationship with Mrs. Smith, and when she did not practice in a client-centred manner. Ashley likely believed that providing the bare minimum amount of nursing care to Mrs. Smith would be sufficient, and that avoiding the client’s undesirable behaviour was the priority in this situation. Unfortunately, Ashley’s avoidance of Mrs. Smith’s care resulted in the client developing a potentially preventable pressure ulcer. In the end, Ashley was thinking primarily of her own wants and needs when she disengaged from Mrs. Smith, and the client ultimately suffered the consequences of Ashley’s under-involvement in client care. Ashley may have avoided breaching the Standards of Practice and Conduct if she had taken time to engage in self-reflection and speak to a trusted colleague or the manager about her concerns.

Reflection Exercises

You may be uncertain if the therapeutic relationship with your client has shifted out of the therapeutic zone into the area of under-involvement. ⁴ Reflecting on the situation and your behaviour may help you understand your feelings and motives and may help you recognize the effect of your actions on the client. ⁵ For instance, the client might not be the only source of stress in your life, so take a minute to think about whether something else is bothering you and whether it affects how you view the client or their actions. ¹⁰ If you are concerned about a potential boundary issue, including being under-involved in client care, you are advised to take steps to address it right away, like consulting with a knowledgeable and trusted colleague or your manager. ⁵

Consider engaging in self-reflection about your nursing practice and the therapeutic relationships you have with your clients, and ask yourself the following questions:

Is my behaviour in the client’s best interest?
Are my actions in the client’s best interest?
Whose needs are being served in this situation?
What impact will this have on the client and their care?
Am I comfortable documenting my behaviour or nursing care in the client’s chart?
How would I feel telling a colleague/supervisor about this?
How could this be viewed by the client’s family or others?
Am I treating this client differently from other clients?
Am I in breach of CLPNM’s Code of Ethics or Standards of Practice and Conduct?
How would I feel about discussing this situation with the CLPNM, in Court, or in a public forum (e.g., on the local or national news) if I were questioned about my behaviour? ¹¹

To help ensure that your professional actions reflect client-centred care and remain within the therapeutic zone on the continuum of professional behaviour, please consider:

recognizing that the client’s well-being is affected by your ability to establish and maintain a therapeutic relationship effectively;
reflecting on interactions with a client and the health care team, and investing time and effort to improve your communication skills;
committing to being available to the client for the duration of care within the employment boundaries and role context;
acknowledging biases and feelings that have developed through life experiences and that these attitudes could affect the nurse-client relationship;
reflecting on how stress can affect the nurse-client relationship;
appropriately managing the cause of the stress so the therapeutic relationship is not affected; and,
acknowledging difficulty establishing a therapeutic relationship with a client and requesting a therapeutic transfer of care when the relationship is not evolving therapeutically (e.g., when a nurse is unable to establish a trusting relationship with a client, they may consult with the manager to request that another nurse provide care). ⁹

Conclusion

The expectation of the CLPNM Standards of Practice and Conduct is that nurses will establish therapeutic relationships and maintain professional boundaries with clients at all times in all settings.^{1, 4} The nurse is responsible for ensuring that their relationship with each client remains within the therapeutic zone on the continuum of professional behaviour. ⁴ No definite lines separate the therapeutic relationship from under-involvement or over-involvement. It is a gradual transition from the center of the continuum (i.e., the therapeutic zone) to either end. ⁷ As such, the continuum of professional behaviour provides nurses with a frame of reference that can help them assess and evaluate their client interactions to correct any gradual shifts from the therapeutic zone to the areas of under-involvement or over-involvement in client care. ⁷

For further reading about therapeutic relationships, professional boundaries, and the continuum of professional behaviour, including under-involvement and over-involvement in client care, consider accessing the resources listed in the references section below.

Next month Your Standards in Focus will be on the topic of Therapeutic Relationships – Over-Involvement in Client Care.

References

College of Licensed Practical Nurses of Manitoba (CLPNM). (2021) Standards of practice and conduct for Manitoba’s practical nurses.
College of Licensed Practical Nurses of Manitoba (CLPNM). (2021) Entry-level competencies for the licensed practical nurse in Manitoba.
College of Licensed Practical Nurses of Manitoba (CLPNM). (2021). Nursing competencies for the licensed practical nurse in Manitoba.
College of Licensed Practical Nurses of Manitoba (CLPNM). (2021). Practice direction: Therapeutic relationships and professional boundaries.
British Columbia College of Nurses and Midwives (BCCNM). (March 21, 2022). Understanding boundaries. Retrieved from https://www.bccnm.ca/RPN/learning/boundaries/Pages/understanding_boundaries.aspx
College of Licensed Practical Nurses of Newfoundland and Labrador (CLPNNL). (2017). Interpretive document: Therapeutic nurse-client relationship. Retrieved from https://www.clpnnl.ca/sites/default/files/2017-04/Therapeutic_Nurse-Client_Relationship_Interpretive_Document_2017.pdf
College of Licensed Practical Nurses of Prince Edward Island (CLPNPEI). (2020). Practice directive: Therapeutic nurse-client relationship. Retrieved from https://clpnpei.ca/wp-content/uploads/2020/05/Practice-Directive-Therapeutic-Nurse-Client-Relationship-2020-05-15.pdf
College of Registered Nurses of Manitoba (CRNM). (2019). Professional boundaries for therapeutic relationships. Retrieved from https://www.crnm.mb.ca/uploads/document/document_file_99.pdf?t=1550609946
College of Nurses of Ontario (CNO). (2006). Practice standard: Therapeutic nurse-client relationship. Retrieved from https://www.cno.org/globalassets/docs/prac/41033_therapeutic.pdf
Correll, R. (2021). Maintaining professional boundaries in nursing. Retrieved from https://www.berxi.com/resources/articles/maintaining-professional-boundaries-in-nursing/
Schunk, S. M. (2014). Professional boundaries: Common dilemmas and a framework for decision-making [PowerPoint Slides]. Prevent Child Abuse Arizona (PCAAZ). Retrieved from: http://www.pcaaz.org/wp-content/uploads/2014/09/A18-Professional-Boundaries-and-Decision-Making.pdf