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  Publications & Resources > The Standard > June 2004 

 Last modified June 9, 2004  

A Different Practice, the Same Standards

Using the professional practice and ethical standards helps nurses navigate complex practice issues such as those found in harm reduction facilities where the client needs present more then basic health issues. They can have legal and ethical ramifications for nurses.

When it’s time to administer meds at Seaton House, an emergency men’s shelter in downtown Toronto, Ross Smith, RN, and his nursing staff face a huge challenge. One nurse cares for 70 clients — that’s 300 doses to get right.

“Some of the clients come to the nursing station, but others who have mental health or other cognitive issues might not remember. They may be sleeping in their room, or somewhere where the nurse with a cart can’t find them,” says Smith, Nurse Manager at this 700-bed facility, where harm reduction is the treatment philosophy.

In almost any practice setting, nurses can find themselves incorporating a number of approaches and strategies to provide the best nursing care possible. Whether it’s managing complex ethical issues, facilitating the well-being of clients displaying aggressive or violent behaviour, or negotiating the therapeutic nurse-client relationship with vulnerable and emotionally fragile clients, nurses work to find solutions that lead to effective, safe and ethical care.

“No matter where you work, no matter how busy or complex your practice, the key to providing safe, effective and ethical nursing care is to know your practice area, your clients, and the regulations and standards for nursing practice,” Janet Anderson, RN, Manager of Practice at the College of Nurses of Ontario (CNO), says.

One complex area comprises the interlaced issues of harm reduction and abstinence. “A lot of people think harm reduction is condoning substance abuse,” Carol Edwards, RN, says. “But abstinence and harm reduction are not two separate theories, and often harm reduction is a good first step to the former.”
Edwards, an acute care nurse practitioner, provides primary health care and education to clients in the residential program at the Centre for Addiction and Mental Health in Toronto. She adds that “harm reduction programs tend to be holistic,” and provide clients with access to non-judgmental health care and education on a variety of health, lifestyle and recovery issues.

These programs can be viewed through a variety of lenses. “Harm reduction is pragmatic in that it accepts that some use of mind-altering substances is common to humanity. It is humanistic in that the dignity of the drug user is respected, free of moral judgments either to condemn or support drug use. In practice, it can mean either reduction of the level of use or an alteration to the mode of use,” says Dyanne Semogas, RN, assistant professor at the McMaster University School of Nursing in Hamilton.

The public health perspective in many countries is that the spread of AIDS among drug users and into the general population is a greater threat to health than the dangers of drug use itself, adds Diane Riley, PhD, assistant professor of Public Health at the University of Toronto and a founding member of the International Association for Harm Reduction.

Examples of harm reduction programs include syringe exchanges, education about safe injection, provision of bleach kits, methadone programs, “tolerance areas” such as supervised injection sites, alcohol programs that prevent impaired driving or promote controlled drinking, and education and outreach programs.

In the Grey Zone

Nurses working in facilities where harm reduction is practised face many challenges. While trying to meet legal obligations, they must refer to their practice and ethical standards, says Semogas, who teaches harm reduction as part of a course on poverty and homelessness at McMaster. “These are constant touchstones that can help nurses in a challenging practice where there are many grey areas.”

Central to CNO’s practice and ethical standards is the concept of facilitating the client’s well-being and preventing or removing harm. How this is defined and achieved may vary from setting to setting. For example, in a harm reduction practice, one of the ways client well-being is fostered is in policies and procedures about infection prevention and control and occupational health and safety.

How a nurse strives for client well-being can be straightforward, or, in practices such as Smith’s, it can take ingenuity, an awareness of hazards in the environment and an understanding of a complex client population and team work. When Smith and his staff began finding used syringes in the laundry hampers and garbage cans at Seaton House, he says staff put the needle disposals in the washroom, instead of near the staff stations, a move that appears to be working.

“This was a cooperative decision among the management team. It offered clients a private means of disposing of syringes and would encourage safety,” says Smith.
Another aspect of nursing that is often overlooked is how to respect client well-being even when the client displays aggressive or even violent behaviour. In any health care setting, there is a potential for unpredictable behaviour among clients. It is vital that nurses have the education and support to prevent, anticipate and de-escalate such behaviour. This includes facility policies and resources that support nurses.

Seaton House has a no-weapons policy, and staff members can call each other for immediate assistance on a two-way radio. Police may be summoned in cases of violence.

When violence does occur, facilities may offer the health care team an opportunity to reflect on the experience through debriefing and open dialogue to promote learning and explore preventive measures.

Building a Foundation

The therapeutic nurse-client relationship is the foundation for providing effective, safe and ethical care. It involves applying nursing knowledge and skill with caring attitudes and behaviours. “It begins the first time you interact with the client and ask him or her what they need and expect,” says Anderson, who works with CNO’s practice team of nurses to provide expert advice on how to interpret and apply the practice standards.

It is this relationship that allows nurses to try to understand the client through listening and ascertaining that person’s short- or long-term goals. “The primary purpose of the therapeutic nurse-client relationship is to meet the needs of the client. You may be answering questions about a particular treatment, for example,” Anderson explains. “You take opportunities to teach and explain, to help clients make informed decisions about their health care.”

“A key element in the therapeutic plan is flexibility,” Smith says. “Over time and through exploration of a client’s unique ways, a therapeutic alliance can be formed to encourage compliance with nutrition, hygiene and medication. This may mean changing medication from evening, when a client wants to be out, to morning when the client is around the shelter.”

According to the practice standard on nurse-client relationships, intimacy, respect and power are essential aspects of the therapeutic relationship, as is the need to maintain boundaries.

In places such as Seaton House, clients may feel that someone cares for them for the first time in years. Without the balance offered by family and friends, clients may misinterpret the nurse’s caring attitude as being more than it is. Sometimes they have to be reminded that it is a professional relationship, says Smith.
Going the other way, it’s possible for a nurse to become too attached to the most vulnerable and needy clients. “Usually other team members notice and point that out,” says Smith.

Another Perspective

Respect in the context of the relationship means the nurse tries to understand the client’s perspective, and to minimize judgment.

Whether clients are using illegal substances or smoking cigarettes, trying to force abstinence before they are ready can cause them to turn away from the health care system and bring greater harm to themselves and the community, Riley says. Respecting where clients are in their lives can give them the time and opportunity to make healthier choices when they are ready.

“We need to think about how we use our power as nurses,” Anderson says. “Instead of trying to influence a client to make a particular decision, we should focus on providing information so the client can make the best decision given the circumstances.”

Client-centered care ensures that clients set their goals according to their own priorities, not according to what others think they should do. Client choice, including self-determination and the right to the information necessary to make choice and to consent to or refuse care, is first and foremost in a harm reduction practice, says Smith.

Building therapeutic relationships with clients who are living with challenging conditions like addiction takes specialized knowledge and experience. The ability to respond appropriately while establishing boundaries and expectations is essential.

Smith and his team look for ways to be approachable in dress and demeanour, so that clients feel safe and comfortable. When the clients do open up, it isn’t always about the most immediate health issues.

“One guy might tell us he wants to get his teeth fixed. Another might say he’d like to start reading again, so he needs a pair of glasses.” Nurses are alert to these cues to facilitate the dental or eye appointments.

However, Smith cautions, “there are times when nurses must assert themselves. A client may be demanding prescription medication but needs an assessment. We have to follow internal policies and professional guidelines.”

Fostering Health

Nurses can also find themselves doing things that are not within their normal scope of practice, but that foster the well-being of clients.

“If they see that the client’s aren’t eating, the nurses might go out and buy some canned ravioli to tempt their appetites. When a client is refusing medication, it may be necessary to exercise negotiation with the client in collaboration with other staff, offering inducements such as cigarettes in return for compliance with medication,” says Smith.

Addictions are complex medical conditions that can often give rise to medical emergencies. The nurses at Seaton House know how to respond. As Smith explains, nurses are usually the first people at a medical emergency, have worked with physicians and are very experienced and used to making independent judgments. However, there is a physician on-call and often in-house who can be contacted in a crisis. Staff can also call 911 if necessary.
Staying competent through continual learning and reflection is vital for any nurse. Staying competent in changing fields such as harm reduction and addiction can be challenging.

In especially difficult situations, nurses need to know when to consult others.
“No matter what type of practice you are engaged in, when a practice or even the needs of a particular client are beyond your knowledge or skill you need to seek help,” says Anderson.

The key to navigating challenging situations lies in using the practiced standards for guidance and information, seeking support from team members, and pursuing continual learning opportunities.

 

Research by Helen Keeler.

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