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June 1, 2020

Practice Expectation Spotlight

Practice Expectation Spotlight: Under Involvement in Care

Are you at risk for under involvement in the therapeutic care of your clients?

Are you at risk for under involvement in the therapeutic care of your clients? Answer this survey question and read the case scenario below to assess your knowledge of risk factors and reflect on your responsibilities to maintain therapeutic nurse-client relationships.

Even though her employer had recently implemented telepractice options for services, Quin Peeters RN was reluctant to take on the use of telepractice for client assessment and care planning because there were so many other changes occurring in recent months. After reflecting on the risks to clients with COVID-19, Quin realized that telepractice may be the option with the most benefits. It would allow her to reach clients while saving time and using less PPE (Personal Protective Equipment). She also felt she could better avoid exposure to anything, which she found to be quite a bonus because of her own anxiety around bringing home any sort of infection.

After a week of providing virtual care visits, Quin began to notice some additional benefits. Some clients appeared to be more open to discussing their health care and others, who were less inclined to engage in care, did not use up her time driving to and from their place. Plus, when there was a bit of a situation with her family at home, she was able to text back and forth during one of her client assessments. The client never even noticed she was only half-listening.

At a team meeting that week, she commented that she “may never do home visits again because telepractice is such a time saver. Clients who really need my services make the effort to figure out the technology and get online for care. Who needs all that exposure to germs anyhow?”

What warning signs for under involvement can you find in this scenario?

  1. Reasoning that texting with her family during a client assessment was ok because the client did not appear to notice
  2. Thinking that if a client needs health care services, they will overcome any challenge in comfort level of communicating and using telepractice
  3. Anxiety about bringing home infections when doing home visits using PPE


Quinn may be experiencing under involvement, that is, too little participation in meeting the care needs of her clients.

The practice expectation for ethical care give her the responsibility to practice according to the values in the code of ethics, which includes care directed first and foremost, toward the health and wellbeing of clients. However, during client assessments, her focus may be more on her family’s and her own needs instead of the needs of her client when she is texting.

In addition, she may not be meeting the responsibility to distinguish technology that enhances nursing practice vs technology that does not. She is assuming that clients who need her services will overcome challenges experienced in using technology. This can be the case for many clients, but it may not be the case for all. She needs to assess for all potential reasons why a client may not engage instead of assuming it is that they do not need health care.

Finally, Quin must consider the evidence regarding the spread of infections when appropriate and necessary PPE is used. All RNs have the responsibility to not spread any infection as outlined in the CRNM practice expectation which states that RN must demonstrate procedures that safeguard the hygiene and sanitation of the practice environment and the hygiene and sanitation of the equipment used in that nursing care. However, there is also the practice expectation to be accountable and responsible for nursing practice that is informed by evidence and demonstrates competence. When Quin states her preference for telepractice over home visits, she may not be taking the current evidence about the spread of infection with use of necessary PPE.

Telepractice does not mean under involvement

This example does not imply that the use of telepractice in and of itself, means that an RN is under involved in a client’s care. Telepractice offers many opportunities for clients to connect where care may not be available otherwise.

This situation provides to opportunity to examine Quin’s reasoning for the use of telepractice, which appears to indicate she is at risk for under involvement in clients’ care.

Recommendation for action

Quin will need to self-reflect on her reasons for preferring telepractice. She will need to ask herself about the current evidence regarding her thoughts on home visits vs telepractice, so that she can make decisions informed by the evidence and based on meeting the needs of her clients.

To help Quin identify the issue, after hearing her comment, another team member or manager could ask Quinn about her comments with the intent to support responsibility and professional development.

A plan of action can be developed for Quin to regain and/or maintain the appropriate level of client involvement, while also meeting all of her practice expectations.