Maintaining Professional Boundaries In A Nurse-Client Relationship

Case Study, Analysis of Communication Behaviors

Focus on the interaction in the video Bevel Up: Drugs, Users and Outreach Nursing that you watched earlier in the module. Review the Two scenarios where the nurses needs to get a blood samplen. Choose one scenario and think about the approach of the nurse in terms of her choice of words, and both verbal and non-verbal behaviour. Now imagine, if you were the nurse seeking the blood sample, what would you do in the following situations? Record your responses in your personal notebook.

The man behaves aggressively. Describe what being aggressive would look and sound like, and what you would do in terms of selected words, and your verbal and non-verbal behaviour in response.

The man behaves passively and ignores your request. Describe what this response would look and sound like, and what you would do in terms of language, verbal and non-verbal behaviour in response.

You are encouraged to refer to the various sources of information provided, to date
 

Importance of Professional Boundaries

A nurse client relationship is defined by professional boundaries and is mainly therapeutic focusing on the needs of the patient. It is the space between the client’s vulnerability and the nurse’s power (Njine & Soroka, 2016; Nmc.org.uk, 2018). Therapeutic relationship is the most effective relationship that exists between the patient and the nurse, while over and under involvement of the nurses and the patients overrides the boundary of the therapeutic relationship. Both over and under involvement of the nurse can give rise to significant harm to the patient. The key components in a nurse client relationship are trust, respect, power and professional intimacy. Boundary violations arise from confusions between the needs of the client and that of the nurse.  Boundary issues arise from over involvement with the client at a personal level or making physical contacts, while under involvement with the client includes being disrespectful, insulting, using a humiliating tone and language, neglecting client needs, among others (Crnns.ca, 2017; Crnbc.ca, 2018). This essay describes the importance of nurse client relationships in order to provide effective care.
 

Professional boundaries in a nurse client relationship are lines that distinguish the therapeutic behavior of the nurses from any form of behaviour that care cause harm to the patients (Cna-aiic.ca, 2017). Staying within this professional boundary helps the nurse to provide safe and effective care in order to meet the needs of the client. Boundary crossings are any form of behaviour that deviates from the professional boundary and may involve actions that may benefit the nurse at the expense of that of the client. Boundary violations are any form of actions or behaviors that are used by nursing professional in order to meet their personal needs without any regards to the needs of the patient. Nurses are required to maintain boundaries by developing a care plan that meets the needs of the client, indicating the client about the limits in the therapeutic relationship, not interfering in the personal matters of the client, not disclosing any form of personal information, not engaging in financial transactions, not engaging in accepting or giving gifts, abusing or neglecting the client, among others. Abuse may involve verbal, physical, emotional or sexual and may also include neglecting the needs of the patient (Cno.org, 2017).

During my service as a mental health nurse, I had experienced a boundary violation in a nurse client relationship. The nurse in the psychiatric unit was looking after an individual suffering from schizophrenia and having a history of substance abuse. Patients with schizophrenia show impulsive aggression and dysfunctional impulsivity. Delusions, hallucinations and hostility give rise to aggressive behavior. Such aggressive behaviors not only harms the individual but also may cause harm to the other patients as well as to the nursing professionals involved in care provision. Aggressive behaviour is “any form of verbal or nonverbal, actual or attempted, conscious or unconscious, forceful means of harm or abuse of another person or object”. Verbal aggression involves shouting, use of abusive language, threats, anger, among others (Moss, 2015). The patient in the psychiatric unit was kept with other patients and was on treatment with anti-psychotics as well as undergoing psychotherapy. However, the patient used to suffer from bouts of aggressive behaviour and it was difficult for the nurse to handle the patient. Unable to control his aggressive behavior the nurse used to engage in using abusive and also locked the patient in an isolated room for long periods of time without determining the cause or providing treatment to the patient.  Thus, these are forms of abuse and neglect, which are boundary violations that the nurse may have unknowingly engaged in (Cno.org, 2017). 

Training for Managing Aggressive Behavior

According to the scenario described above, the best intervention would be to train the nurse about the various strategies that can be applied to control the patient as well as prevent harm to the patient. In order to prevent harm to other patients, the nurse may have taken this step, which in turn unknowingly violates the nurse patient professional boundaries. Thus, it is necessary for her to re-establish the relationship by undergoing training to determine the effective strategies to manage the patient’s violent behaviour.  De-escalation technique is an effective way of controlling aggressive or violent patient behaviors (Berring, Pedersen & Buus, 2016). NICE recommends the use of de-escalation techniques in order to manage aggressive behaviors of patients. De-escalation is a range of psychosocial interventions that helps in re-directing the patient towards a calm mental space. It involves the use of staff skills and intervention strategies. These include maintaining a safe distance from the client, staying calm, showing empathy, showing genuine interest in determining the patient’s concern, isolating the individual, reasoning with the individual to come to a common ground, speaking in a normal tone, volume and rhythm, not argue, confront or be judgmental, acknowledging the patient complaints and clearing any form of misconceptions, providing realistic solutions and calling for backup if the need arises. Other interventions include training for the utilization of restraining techniques. These activities in turn will help the nurse to manage the situation by calming the individual and also prevent any form of harm or wrongdoing to the individual (Nice.org.uk, 2015).

Therapeutic communication is the use of a wide variety of effective communication strategies as well as interpersonal skills that help to establish, maintain, re-establish or terminate a nurse-patient relationship. Therapeutic communication skills are forms of verbal or nonverbal techniques that encourage the exploration of feelings and help in the fostering of behavioral motivation by being non-judgmental, not being defensive and by promoting trust (Abdolrahimi et al., 2017).  If a patient is showing an aggressive behaviour, it is necessary for the nurse to present a calm appearance, speak in a soft tone and in a non-judgmental manner, maintain space and show respect, maintain control of the situation, among others. It is also necessary to listen to the patient in order to determine the patient’s concern, give suggestions and positive feedback. It is also necessary to make the patient understand about the situation by describing the symptoms and the necessary tests, so that the patient is fully engaged in the situation and does not ignore the request of the nurse (Punjani & Bhanji, 2013). 

De-escalation Techniques for Managing Aggressive Behaviors

With respect to the scenario described above, the communication strategies, which the nurse can adapt in order to establish a therapeutic relationship with the client is to give the client the time, ability and opportunity to explain his concerns and problems. Moreover, the nurse should participate in active listening without giving any advice or judgment with respect to the situation. This will enable the nurse to gain the trust of the patient as the patient will understand that the nurse has his best interests in mind. The nurse should also communicate in a soft tone rather than being harsh or sarcastic about the situation. Another strategy that the nurse can adapt is to provide information to the client, respecting the values and beliefs of the client and integrating these into the care plan and also enabling the client to make informed decisions (Cno.org, 2017).

Therapeutic communication is an effective way of maintaining the professional boundaries in a nurse-client relationship. Active listening, providing sufficient time to the clients by not being impatient and using appropriate verbal and non-verbal communication strategies help in the continuity of safe and effective care and also in the maintenance of a responsible nurse-client therapeutic relationship. The decision tree is a tool that helps to carry out self-reflection as well as self-evaluation of the activities or behaviors that a nurse engages in when providing care to a patient (Cno.org, 2017). Thus, maintaining such therapeutic communications would enable the nurse to provide effective care to the patient, without violating the professional boundaries. 

Conclusion

Effective communication is the cornerstone to establishing a therapeutic relationship with the patient. It is characterized by active listening, open-ended questions, empathy as well as assertiveness. Effective or therapeutic communication also falls within the professional boundaries in a nurse client relationship. Violations of such boundaries results in harm to the patients. Training and self-reflection plays an important role as it enables the nurses to participate in therapeutic communication and maintain professional boundaries. 

Reference List

Abdolrahimi, M., Ghiyasvandian, S., Zakerimoghadam, M., & Ebadi, A. (2017). Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic physician, 9(8), 4968.

Berring, L. L., Pedersen, L., & Buus, N. (2016). Coping with violence in mental health care settings: patient and staff member perspectives on de-escalation practices. Archives of psychiatric nursing, 30(5), 499-507.

Cna-aiic.ca. (2017). Code of ethics for registered nurses. Cna-aiic.ca. Retrieved 9 February 2018, from https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/code-of-ethics-2017-edition-secure-interactive.pdf?la=en

Cno.org. (2017). Therapeutic Nurse-Client Relationship, Revised 2006. Cno.org. Retrieved 9 February 2018, from https://www.cno.org/globalassets/docs/prac/41033_therapeutic.pdf

Crnbc.ca. (2018). Boundaries in the nurse-client relationship. Crnbc.ca. Retrieved 9 February 2018, from https://www.crnbc.ca/Standards/resourcescasestudies/ethics/nurseclientrelationships/boundaries/Pages/Default.aspx

Crnns.ca. (2017). Professional Boundaries and the Nurse-Client Relationship: Keeping it Safe and Therapeutic Guidelines for Registered Nurses. Crnns.ca. Retrieved 9 February 2018, from https://crnns.ca/wp-content/uploads/2015/02/ProfessionalBoundaries2012.pdf

Moss, R. L. (2015). Communication Skills of Novice Psychiatric Nurses with Aggressive Psychiatric Patients(Doctoral dissertation, Walden University).

Nice.org.uk. (2015). Violence and aggression: short-term management in mental health, health and community settings. Nice.org.uk. Retrieved 9 February 2018, from https://www.nice.org.uk/guidance/ng10/resources/violence-and-aggression-shortterm-management-in-mental-health-health-and-community-settings-1837264712389

Njine, D., & Soroka, B. (2016). Good quality interaction between the registered nurse and the patient: a systematic review.

Nmc.org.uk. (2018). The Code: Standards of conduct, performance and ethics for nurses and midwives. Nmc.org.uk. Retrieved 9 February 2018, from https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-old-code-2008.pdf

Punjani, N. S., & Bhanji, S. M. (2013). Role Of Therapeutic Communication In Dealing With Aggressive Patients. i-Manager's Journal on Nursing, 3(4), 29