2. A working relationship
• Health and social care practitioners all
need to be able to establish and
maintain a good working relationship
with their service users.
• This is particularly demanding with
service users who are uncertain about
engaging with your service and need to
trust you in order to work effectively on
their issue.
• The practitioner-client relationship,
arguably, is a core factor in successful
provision for this service user group.
3. A working relationship in social
care (Galvani 2012)
• Establishing a good working
relationship with people who use
substances is vital in order to maintain
engagement and trust.
• An empathetic and non-judgemental
working relationship is important when
working with a client group who may
be used to experiencing stigma and
stereotyping.
4. A working relationship in
nursing (Miller & Nambiar-Greenwood, 2009)
• The principles of the nurse-patient
relationship are the same as social care
although might borrow more from
therapeutic relationship evidence.
• A nurse-patient relationship needs to be
based on trust. A client needs to be able
to trust the practitioner is not going to
judge them. The client should be able to
tell the practitioner anything which
relates to the issue involved. Where this
issue is the holistic impact from
substance misuse, disclosure could be
about any number of things.
5. Professional boundaries
(Miller & Nambiar-Greenwood, 2009)
• Arguably, when working with people who can be challenging to
engage, trust is established by secure maintenance of the
relationship boundaries.
• These boundaries need to be made clear to the person you are
working with.
• A service user needs to be able to disclose worries or
embarrassing questions. Boundaries of confidentiality, respect and
unconditional positive regard all help in supporting this.
6. Case example: Jason
• Jason is an injecting drug user admitted to
hospital following an accidental overdose.
He is kept in overnight for observation.
• During the admission interview, he says
cautiously that he is too experienced to have
‘an accident’.
• Without any judgement or shock, the nurse
simply feeds back to him that he attempted
suicide. Jason nods and says he wants to
die.
7. Case example: Jason (cont)
• In this example, the nurse handled a sensitive disclosure
unconditionally and with apparent confidence. This meant that
Jason could elaborate on his disclosure and he opened up to
discuss his mental state.
• The professionalism of the practitioner gave Jason confidence to
disclose after ‘testing the nurse out’ with a hint about his suicide
attempt.
• Alcohol and drug users have a higher than average risk of
suicide. Thus we have a professional duty of care to address this,
especially when they offer us a lead into this difficult conversation.
8. Boundaries
• So what are ‘boundaries’ that encapsulate the practitioner-client
relationship?
• The Nursing and Midwifery Council (NMC) (2008) define these as
good for the patient/client and facilitative of care/support.
• The NMC (2009) also identify that boundaries protect the
practitioner, especially for students who are learning to manage
what is not a normal environment for them.
• Professional values and boundaries within social care are defined
by Codes of Ethics and guidance on professional boundaries. As
with NMC guidance, the focus is on respectful relationships
encompassing honesty, integrity, and empowerment (General Social
Care Council, 2009).
9. Case example: Anne
• Anne is an affluent and isolated 66 year old who has crippling
arthritis, depression and alcohol dependency.
• A community mental health nurse visits regularly to monitor and
support Anne. The nurse often complains that her car is falling
apart. On this occasion, Anne offers to loan the nurse the money to
get it repaired. The nurse is desperate and accepts.
• How may this action harm Anne?
10. Case example: Anne – possible
answers
• Exploitation of Anne’s vulnerability and reliance on the nurse.
• Moving the focus of support from Anne to the nurse.
• Financial abuse – inappropriate use of the client’s funds or property.
• Distorting the boundaries of trust and whose needs are prioritised.
• Potential for further exploitation of the client or manipulation of the
nurse.
11. Boundaries (NMC 2009)
Maintain your professional boundaries with your client by:
– Ensuring it is focused solely on the client’s and family’s health
and wellbeing.
– Ensuring that you are there only as a practitioner (not a friend,
neighbour, relative, etc).
– Honouring confidentiality where appropriate.
– Maintaining a proper appointment system.
– Getting help for yourself if you are in crisis.
– Consulting with colleagues about difficult situations.
– Refraining from over-familiarity .
– Not accepting or giving gifts (check for team policies).
12. Protecting yourself
• Professional boundaries protect both the
service user and the practitioner.
• There are other ways your practice is
protected when working with any client
group but more especially when working
with vulnerable service users.
• Check your team’s lone working policies,
policies on violence and aggression and
any policies on the presence of drugs on
the premises.
13. Protecting yourself - tips
• Never work alone if you feel in any way unsafe with a client. You
should be protected by your team’s policy on this.
• Interviewing someone who is highly intoxicated is often unproductive
and may put you at risk. Ensure normal meetings with your
patient/client are carried out when the person is not under the
influence or you have someone with you.
• Do not condone possession or exchange of illegal
substances in your presence. You can be prosecuted
for aiding and abetting drug dealing if you do not take
precautions. Ensure your clients know not to bring
substances with them to any interview or appointment.
• Do not give a client your personal phone number or home address.
14. References
• Galvani , S. (2012) Supporting People with Alcohol and Drug Problems. Bristol: Policy
Press.
• Miller E & Nambiar-Greenwood G (2009) The Nurse-Patient Relationship, In:
(Webb) Nursing: Communication Skills in Practice. Oxford, Oxford University Press.
• NMC (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses
and Midwives. London, Nursing and Midwifery Council.
• NMC (2009) Clear Sexual Boundaries. London, Nursing and Midwifery Council.
