Standards in Focus

Therapeutic Relationships: Over-Involvement in Client Care

July 21, 2022

A therapeutic relationship is one that remains within the therapeutic zone on the continuum of professional behaviour. Client harm can occur when the relationship strays into under-involvement or over-involvement in client care.

This edition of Standards in Focus is a continuation of the edition published in June of 2022 which highlighted Standards related to the therapeutic relationship, and specifically, those relating to under-involvement in client care. This edition explores the risks associated with over-involvement in client care.

Over-involvement refers to an unnecessary focus on a client that goes beyond what is necessary for their care, or providing care beyond the nurse’s scope of employment. ⁴ An LPN becoming over-involved in client care can look like favouritism, social/personal relationships with clients, or even abuse (i.e., physical, emotional, verbal, sexual, or financial). ⁸ It is important to note that over-involvement does not refer to a nurse appropriately prioritizing a client’s needs because of increased complexity in their care. ⁴

Over-involvement can affect the recovery of other clients. For instance, the nurse may fail to allocate their time appropriately and may fail to identify and address other clients’ needs. Over-involvement with one client may also lead other clients to feel that their health is not important to the nurse, causing them to refrain from seeking assistance. ⁴

Over-involvement can harm the client when that over-involvement violates the boundaries of the professional therapeutic relationship. ⁴ A boundary violation occurs when the client’s needs are no longer the focus of the therapeutic relationship. The nurse places their own needs above those of the client. ^{4, 8} Nurses must understand the potential for adverse client outcomes if boundary violations occur. Boundary violations can cause distress for clients, which may not be recognized or felt until harmful consequences arise. ⁵ Client consent to or initiating a personal relationship is not a defence. Nurses are to act as a client advocate and, when appropriate, intervene to prevent or stop boundary violations. ⁸

Examples

Some examples of over-involvement and boundary crossings or violations that can harm the nurse-client therapeutic relationship include:

showing favouritism to a client;
discussing the nurse’s personal issues with a client (i.e., excessive personal disclosures)
speaking poorly about colleagues or your employment setting with the client;
referring to each other as friends and/or accepting friend/follow requests from clients on social media platforms (e.g., becoming friends on Facebook);
the client having the nurse’s personal contact information (e.g., cellphone number, email address, home address, etc.);
having a personal or business relationship with a client;
requesting or accepting special favours or expensive gifts;
visiting clients while off-duty, and/or socializing with a client outside of the professional setting; and/or,
acting as a representative for clients (e.g., being the client’s power of attorney). ^{4, 6, 7, 8, 11}

Some examples of extreme boundary violations include:

consensual or non-consensual sexual encounters with clients;
exploiting the therapeutic relationship for the nurse’s emotional, financial, sexual or personal advantage or benefit; and/or
abuse (physical, verbal, emotional, sexual, or financial).^{4, 6, 7, 8}

Abuse is a boundary violation and an extreme example of harmful over-involvement. Abuse is an ethical breach that can result from a misuse of power, a betrayal of trust, or a betrayal of the respect inherent in the nurse-client relationship. Abuse may take many forms, including physical, verbal, emotional, sexual, and/or financial abuse. Mistreatment of a client may be considered abuse when it is reasonably likely to cause death, serious harm, or significant property loss. Any form of client abuse is a serious boundary violation. ⁴ Abuse or neglect of a client may result in CLPNM disciplinary action, including a license suspension or cancellation, a report and investigation under The Protection for Persons in Care Act, or criminal charges. ⁴

Please access the resources listed in the references section below for more examples of boundary crossings and/or boundary violations.

Terminating the Therapeutic Relationship

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. ^{6, 9} For example, the nurse should inform the client that it is their last shift together, the client’s care is being transferred to another nurse, or the client is being discharged. ^{6, 9} To provide the client with even a hint or the hope that the relationship will continue is inappropriate, unprofessional, and unethical (e.g., the nurse informs the client that they may contact the client on social media to check on their condition after discharge). ⁶ This means that the nurse must not agree to or imply that there might be an ongoing relationship between the nurse and client following the termination of the nurse-client therapeutic relationship. ⁴

Ultimately, the nurse’s responsibility is to meet the needs of the client. Suppose the nurse feels that they cannot meet the needs of the client and feels at risk for over-involvement in the client’s care. In that case, the nurse must seek guidance or assistance from their colleagues, manager, or employer. ⁶

Nursing Practice Scenario

The following scenario shows how over-involvement in client care can develop gradually, unintentionally, and subtly over time if the nurse is not vigilant in maintaining professional boundaries:

Tim Reynolds, LPN, works on a medical unit where Mr. Thompson, a 48-year-old male client, has been admitted for the past two months. He has been part of Tim’s client assignment for four weeks. The two men have struck up a friendship because they are close in age and have many things in common. For instance, both have lost a brother to separate accidents, and they bonded over this shared experience.

One day, Tim steps off the elevator and heads towards his unit, where he runs into his colleague Angela, LPN. “Hey, Tim! Isn’t today your day off? What are you doing here?” Angela exclaims. Tim is carrying two coffee cups and says, “I’m just dropping off some coffee for a friend.” Angela gives Tim a questioning look when she observes him going into Mr. Thompson’s room. Tim has coffee, speaks with Mr. Thompson for approximately 20 minutes, and then he leaves to run some personal errands. Tim reencounters Angela on his way out. She says, “Be careful that you aren’t blurring the lines between professional and personal relationships, Tim.” She reminds Tim that Mr. Thompson is his client, not his friend.

Tim had never done anything like this before, and when he offered to bring Mr. Thompson coffee on his day off, it didn’t seem like a big deal. Angela’s reaction makes him pause and think about what has occurred. Tim recalls that, over the past few weeks, his conversations with Mr. Thompson have become more and more personal as they discovered they had similar experiences and interests. Tim reflects on the fact that he began spending many of his breaks in Mr. Thompson’s room. Small favours, like picking up a newspaper every morning for Mr. Thompson, or giving Mr. Thompson his personal cellphone number, seemed harmless at the time. Now Tim isn’t so sure.

Tim recalls hearing that Mr. Thompson recently refused to have wound care done by another nurse, stating in front of other clients, “I’ll wait for my nurse friend Tim to come back to work in a couple of days.” Tim laughed it off at the time, but now sees that his professional boundary crossing led to Mr. Thompson putting off a needed dressing change for several days, which may have put him at risk for further skin breakdown and infection. Tim also reflects on comments he’s heard from other clients about his relationship with Mr. Thompson. Tim realizes that the perception that he favours Mr. Thompson, over other clients, may impact his other clients’ trust in him and affect the therapeutic relationship.

The next morning, Tim discusses the situation with Angela. She gives him some suggestions for how to re-establish boundaries with Mr. Thompson. Tim’s first step will be to explain the situation to Mr. Thompson and let this client know that he’ll be acting differently and more professionally from now on. Reflecting further on the situation over the next few days helps Tim understand his behaviour and feelings and recognize the effect of his actions on his client, his other clients, and the health care team.

Tim’s behaviour in the practice scenario is an example of a nurse breaching several of the Standards of Practice and Conduct. Standard 23 speaks to expectations that the nurse must identify potential and actual risk and take action to safeguard clients. ¹ Furthermore, Standard 37 states that nurses must provide nursing care that is client centred, which includes advocating for clients by actively supporting, protecting, and safeguarding their rights and interests. ¹ Finally, Standards 30-36 refer to expectations that nurses must establish, maintain, and end therapeutic relationships with clients. ¹ In particular, Standard 34 states that nurses must ensure that the client’s therapeutic needs remain the focus of the therapeutic relationship. ¹

In the practice scenario, Tim failed to assess, identify, or address potential and actual risks to the client’s well-being. He did not identify how his boundary crossing with Mr. Thompson, which shifted his relationship from the therapeutic zone to over-involvement in care, could potentially negatively affect Mr. Thompson. Tim also breached the Standards when he failed to maintain the therapeutic relationship with Mr. Thompson and did not practice in a client-centred manner. His actions were no longer solely focused on meeting Mr. Thompson’s health care needs. Tim let his desire to connect with someone, who shared a personal experience with him, affect his client care and take precedence over his clients’ interests.

Although Tim’s actions were inconsistent with his profession’s Standards of Practice and Conduct, Tim did his best to rectify the situation by reflecting on his actions and by taking steps to return the professional relationship with Mr. Thompson to the therapeutic zone.

Reflection Exercises

You may be uncertain or wondering if the therapeutic relationship with your client has shifted out of the therapeutic zone on the continuum of professional behaviour into the area of over-involvement. ⁴ Reflecting on the situation outlined above and exploring your concerns may help you understand your feelings and motives and recognize the effect of your own actions on your clients. ⁵

In situations where you may be at risk for over-involvement in client care, try to stay self-aware and err on the side of caution when interacting with your clients. ¹⁰ For instance, be honest with yourself about your feelings toward the client, and be extra mindful about what you say or do around them. Even though you may feel comfortable around a certain client, you must not be complacent in your professional duties toward them and others you care for. ¹⁰

Consider engaging in self-reflection about your nursing practice and the therapeutic relationships you have with your clients. When faced with a situation that places you at risk for over-involvement, 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?
Does this action benefit the client or me?
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 was 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 as the nurse to effectively establish and maintain a therapeutic relationship;
reflecting on interactions with a client and the health care team, and investing time and effort to continually improve 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 recognizing that these attitudes could affect the nurse-client relationship;
reflecting on how stress can affect the nurse-client relationship and appropriately managing the cause of the stress, so the therapeutic relationship isn’t 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

If you’re concerned about a potential boundary issue, including being over-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

Conclusion

As per the CLPNM Standards of Practice and Conduct, nurses are expected to establish therapeutic relationships and maintain professional boundaries with clients at all times in all settings. ^{1, 4} In other words, the nurse is responsible for ensuring that their relationship with each client is a professional and therapeutic relationship that 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; instead, 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.

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