Evidence-Informed Client-Centred Care

Scenario
Nick has recently immigrated to Canada as a healthcare professional knowledgeable about science, his health, and well-being. He is also someone who participates in MSM (Men who have Sex with Men) activity and prefers not to disclose his sexual identity. In reviewing sexual health literature, Nick found that a medication typically used to prevent respiratory infections in the elderly is also being used with moderate success in younger adults to prevent syphilis.

Though Nick had concerns regarding stigma and disclosing his sexuality, he met with his physician to discuss whether he could obtain this medication. The physician explained that the medication was not approved by Health Canada for his condition but agreed to prescribe it off-label based on current evidence, with no significant risks.

When Nick visited the pharmacy, he discovered that the medication required an injection. He was directed to a nearby clinic for administration. There, Richard, a registered nurse, assessed Nick and, after discussing the treatment with the on-call nurse practitioner, told him that he couldn’t give the medication because Health Canada hadn’t approved it for the prevention of syphilis, let alone his age group.

Nick explained that his doctor had discussed this off-label use with him, and it was based on evidence, but Richard remained firm, saying that giving the medication is not indicated and that his prescriber was mistaken. Feeling dismissed and uncomfortable, Nick left the clinic without receiving his medication.

While Richard was correct in wanting to ensure safe and appropriate medication administration, a stronger focus on evidence-informed practice, collaboration, and ethical care might have led to different outcomes. Off-label prescribing is a recognized and legal practice in Canada when supported by clinical evidence and the prescriber’s professional judgment.

In this scenario, the communication among the nurse, client, and prescriber led to a breakdown in trust and continuity of care. It also reinforces that safe, ethical, and client-centred care is built not only on rules and evidence, but also on respect, humility, and reflective practice.

How This Situation Could Have Turned Out Differently

1. Evidence-Informed Judgment

Uncertainty is omnipresent in clinical practice. Scientific uncertainties can be exploited in ways that undermine the integrity of our decisions and foster distrust among the public. In this case, Nick felt alienated when the evidence he provided and his prescribers’ knowledge were ignored, which, to him, felt like favouring Health Canada’s guidelines over his evidence and healthcare needs.

While Richard was correct to seek out more information about the treatment, he could have demonstrated humble inquiry by engaging Nick in decision-talk. Explaining to Nick that he did not feel confident administering the treatment is an appropriate response in this situation and can help equalize relationships with the patient. By showing humility, Richard may be better equipped to stress that off-label use carries risks for both of them. From this vantage point, the discussion changes from a win-lose to a win-win discussion. Nick can share what he knows about the treatment, and Richard can examine the relevant studies with him as a partner in care. Calling the physician and/or pharmacist to ensure the prescription was correct would have clarified the clinical rationale and confirmed that the medication was appropriately prescribed.

By taking these steps, Richard would have upheld his professional responsibility to use critical evidence-informed thinking while also protecting and reassuring the patient.

2. Collaboration and Client Autonomy

Evidence-informed decision-making requires incorporating patients’ values and preferences into the decision. When patients are not directly involved in decision-making, they may perceive the process as paternalistic. In this case, Nick felt he was well educated about his condition and the treatment, but was nervous to discuss a stigmatized condition. Not involving him in the decision was interpreted as further stigmatization when his choices were not respected. Richard could have invited Nick into a more open dialogue, validating Nick’s expertise as both a healthcare professional and a client. This approach would involve being transparent about one’s breadth and depth of knowledge and creating space for shared problem-solving.

Communicating that care can occur in silos and emphasizing the importance of involving the client’s physician or pharmacist would have further promoted a team-based approach to safe, effective care, while also demonstrating a willingness to meet the client’s care objectives.

3. Ethical and Culturally Safe Practice

The scenario also highlights the importance of ethical care and awareness of power imbalances within the therapeutic relationship. As a regulated health professional, Richard holds structural power that can significantly influence how clients access and experience care. Such an imbalance can and has been exploited to deny or delay healthcare for groups that have historically been unable to advocate for themselves, unlike those in positions of privilege. Even when care is withheld for legitimate safety reasons, the tone and approach must convey respect, empathy and understanding of the client’s perspective.

Richard could have:

Recognized Nick’s knowledge and self-advocacy as valuable.
Recognized how his position of privilege influences how he or the client feels and responds to a situation.
Sought a win-win approach to resolving disagreements and differences of opinion. This contrasts with a win-lose situation, where the clinician assumes they know best and, in the process, potentially denies the client the care they need or want.

References

College of Registered Nurses of Manitoba. (2022). Practice Expectations for RNs. https://www.crnm.mb.ca/resource/practice-expectations-for-rns/

Djulbegovic, B. (2021). Ethics of uncertainty. Patient Education and Counseling, 104(11), 2628-2634.