Practice Expectation Spotlight: Providing Registered Nursing Care to Family Members 

Drew Darren, RN(NP), has completed formal instruction in footcare. She owns and operates the only foot care practice in a remote rural community. Her family member was recently diagnosed with diabetes mellitus and Drew wonders if she will be able to provide routine and preventative foot care, or if her family member will have to travel elsewhere.

Drew decides to consider what she should do, and she starts to review Practice Directions and supporting documents on the College of Registered Nurses of Manitoba’s (College) website. Here are some of the things she considers: 

1. The College Document Professional Boundaries for Therapeutic Relationships provides guidance for Registered Nurses who are considering entering into a therapeutic relationship with friends or family. It notes that,
   While this is generally not appropriate, due to the inherent conflict of interest present in the relationship, there may be circumstances where such a situation is unavoidable. Prior to entering into a therapeutic relationship under these circumstances, the nurse should ensure that attempts to exercise other options have been exhausted or that other options do not exist. Drew contemplates alternative options such as foot care in neighboring communities, and the safety, feasibility or appropriateness for her family member to leave the community to get care.  
2. Drew knows that both the Practice Direction: Practice Expectations for RN(AP)s and Practice Direction: Practice Expectations for RN(NP)s explicitly forbid prescribing medications to family members. Though Drew is only considering providing footcare services, she understands that, if her family member requests that she prescribes medications, she will not be able to assist them.
3. The Practice Direction: Practice Expectations for RNs requires RNs to “appropriately document the nursing care you provided in a record specific to each client as the nursing care is provided or as soon as possible after the care is provided.” Drew reflects that, if she chooses to provide care to her family member, she will have to document the care provided in a health record, as with other patients. Providing care “off the books” would not be acceptable practice.
4. The Practice Direction: Practice Expectations for RNs requires RNs to provide nursing care that includes an assessment, a care plan, and an evaluation of outcomes. Drew considers how her current relationship with her family member(s) may impact the care that she provides. She considers the following questions: 
   
   • Will her existing relationship impact her ability to assess her family member?   
   • Will her family member feel comfortable providing her with the details of their health history that are needed to provide care?  
   • Will Drew feel comfortable asking for that information?  
   • Will Drew be able to objectively formulate a care plan for her family member?  
   • Will their familial relationship cause Drew to feel pressured to provide care that she would not usually provide?  
   • Will Drew be able to objectively evaluate the care she provides? 
   •  Will her familial relationship cause her to over or underestimate the effectiveness of the care she provided?  
   • If Drew is required to inform her family member of a negative outcome or “bad news”, will her personal relationship make this difficult?
5. The Code of Ethics for Registered Nurses broadly defines family as “those people identified by the person receiving or in need of care who provide familial support” and requires that family be involved where required, as directed by the patient. Drew realizes that she needs to consider how the therapeutic relationship would also need to involve other family members in the circle of care. Is she able to work therapeutically with other family members? 
6. The Entry-Level Competencies for RN(NP)s require RN(NP)s to “identify and manage potential and real conflicts of interest, always acting in the client’s best interest.” Drew knows that, if she decides to provide care for her family member, there will be a conflict of interest that results from their pre-existing relationship. If she decides to proceed, she will need to have a plan in place to make sure that her actions are always in her client’s best interest.
7. The Code of Ethics for Registered Nurses requires RNs to “make fair decisions about the allocation of resources under their control based on the needs of the person receiving care”. Drew must not allow her familial relationship to impact decisions including how much she will charge her family member, how she will book her family member’s appointments in her busy schedule, and how she will use scarce material resources (i.e., dressing supplies and tools). She will need to have a plan in place to make sure those decisions are made without improper influence. 
8. Drew is familiar with the College’s  Professional Boundaries for Therapeutic Relationships document and understands that nurses need to work within the “zone of helpfulness” and avoid boundary violations. As a self-employed nurse, she is extremely autonomous and rarely has a colleague present while she works. If her familial relationship causes her to become over or under-involved, who is available to point out these concerns? In the event of a boundary violation, who is present to assist her?  

After considering all of these things, Drew is still unsure how she should proceed. Before entering a therapeutic relationship with her family member, Drew decides to contact a Quality Practice Consultant with the College for additional advice and information (practice@crnm.mb.ca) 

Additional Resources 

Practice Direction: Self-Employed Practice  

Self-Employed Practice Handbook