the college of nurses of ontario presents the therapeutic nurse client relationship revised 2006 practice standard maintaining boundaries four standard statements describe what a nurse is accountable for in the therapeutic nurse client relationship each statement has accompanying indicators which are broad statements that nurses can modify to their particular practice reality the standard statements are therapeutic communication client-centered care maintaining boundaries and protecting the client from abuse in this chapter we'll discuss maintaining boundaries the standard statement for maintaining boundaries states that nurses are responsible for effectively establishing and maintaining the limits or boundaries in the therapeutic nurse client relationship when a nurse violates or crosses the boundaries in a therapeutic relationship the nature and dynamic of the relationship change the balance of power between the nurse and the client becomes even more unequal and this increases the client's vulnerability a nurse maintains boundaries by developing a comprehensive plan of care with the client that aims to meet the client's needs following the plan of care and recognizing that certain practice settings require increased vigilance to maintain boundaries for example when providing care in a client's home a nurse has an increased risk of becoming involved in the family's private life a nurse accepting a gift from a client is another example of a boundary crossing a nurse maintains boundaries by not accepting a gift from a client unless in the rare instance the refusal will harm the therapeutic relationship if refusing a gift would harm the therapeutic nurse client relationship the nurse should consult with the manager and document the consultation ensure that the gift wasn't solicited clarify the client's intent in offering the gift assess the appropriateness of the timing of the gift and consider the monetary value of the gift for example if on discharge a client wants to thank the nurses by making a small contribution to the units education fund it would be considered appropriate however it would not be appropriate for a nurse to accept a client's offer to pay for a course that the nurse wants to take there are a number of warning signs that a nurse may be at risk of crossing a boundary in the therapeutic nurse client relationship nurses need to reflect on the situation and seek assistance if any of the following warning signs are present spending extra time with one client beyond the therapeutic relationship changing client assignments to give care to one client and telling the client personal information that does not contribute to the therapeutic relationship nurses also need to reflect on the situation and seek assistance if they find they are dressing differently when they know they'll be seeing a specific client frequently thinking about the client spending off-duty time with the client and ignoring agency policies when working with the client nurses must not only be aware of their own behavior they must be cognizant of their colleagues behavior in therapeutic relationships if you believe that a colleague is crossing a boundary assess the situation and speak to the colleague about what you saw how that behavior is perceived and the impact on the client nurse relationship refer the colleague to the college's ethics and therapeutic nurse client relationship practice standards if you can't speak with a colleague directly or the colleague doesn't recognize the problem speak to the colleague supervisor also document the concerns in writing include a description of the event that suggested a boundary crossing the date and time of the event the names of witnesses to the event and some type of client identification such as initials or a file number you have now completed chapter four to work through another chapter in this module close this presentation and return to the learning center