104 Unit 2 BUILDING THENURSE–CLIENTRELATIONSHIPAdvocate
In the advocate role, the nurse informs the client
and then supports him or her in whatever decision
he or she makes (Kohnke, 1982). In psychiatric-
mental health nursing, advocacy is a bit different
from medical-surgical settings because of the nature
of the client’s illness. For example, the nurse cannot
support a client’s decision to hurt himself or herself
or another person. Advocacyis the process of act-
ing in the client’s behalf when he or she cannot do so.
This includes ensuring privacy and dignity, promoting
informed consent, preventing unnecessary exami-
nations and procedures, accessing needed services
and benefits, and ensuring safety from abuse and ex-
ploitation by a health professional or authority figure.
For example, if a physician begins to examine a client
without closing the curtains and the nurse steps in
and properly drapes the client and closes the curtains,
the nurse has just acted as the client’s advocate.
Being an advocate has risks. In the previous ex-
ample, the physician may be embarrassed and angry
and make a comment to the nurse. The nurse needs
to stay focused on the appropriateness of his or her
behavior and not be intimidated.
The role of advocate also requires the nurse
to be observant of other health care professionals.
Peternelji-Taylor (1998) describes the “conspiracy
of silence”that prevails, whereby staff members go
to great lengths to avoid seeing what is happening or
becoming involved when a colleague violates the
boundaries of a professional relationship. Mohr &
Horton-Deutch (2001) write that nurses must over-
come peer pressure to go along and get along with
others and regain their “moral voice” to speak up
about what is right for the client when they observe
neglect, disinterest, or callous, uncaring treatment of
clients. Nurses must take action by talking to the
colleague or a supervisor when they observe bound-
ary violations. State nurse practice acts include the
nurse’s legal responsibility to report boundary vio-
lations and unethical conduct on the part of other
health care providers. There is a full discussion of
ethical conduct in Chapter 9
There is debate about the role of nurse as ad-
vocate. There are times when the nurse does not
advocate for the client’s autonomy or right to self-
determination such as supporting involuntary hos-
pitalization for a suicidal client. At these times, act-
ing in the client’s best interest (keeping the client
safe) is in direct opposition to the client’s wishes. Some
critics view this as paternalism and interference with
the true role of advocacy. In addition, they do not see
advocacy as a role exclusive to nursing but also the
domain of physicians, social workers and other health
care professionals (Hewitt, 2002; Hyland, 2002).Parent Surrogate
When a client exhibits childlike behavior or when a
nurse is required to provide personal care such as
feeding or bathing, the nurse may be tempted to as-
sume the parental role as evidenced in choice of words
and nonverbal communication. The nurse may begin
to sound authoritative with an attitude of “I know
what’s best for you.” Often the client responds by act-
ing more childlike and stubborn. Neither party real-
izes they have fallen from adult–adult communication
to parent–child communication. It is easy for the client
to view the nurse in such circumstances as a parent
surrogate. In such situations, the nurse must be clear
and firm and set limits or reiterate the previously setBox 5-4
➤ POSSIBLEWARNINGS ORSIGNALS OFABUSE OF THENURSE–CLIENTRELATIONSHIP
- Secrets, reluctance to talk about the work being done with clients
- Sudden increase in phone calls between nurse and client or calls outside clinical hours
- Nurse making more exceptions for client than normal
- Inappropriate gift-giving between client and nurse
- Loaning, trading, or selling goods or possessions
- Nurse disclosure of personal issues or information
- Inappropriate touching, comforting, or physical contact
- Overdoing, overprotecting, or over-identifying with client
- Change in nurse’s body language, dress, or appearance (with no other satisfactory explanation)
- Extended one-on-one sessions or home visits
Adapted from Walker, R., & Clark, J. J. (1999). Heading off boundary problems: clinical supervision as Risk Management. Psychi-
atric Services, 50(11), 1435–1439.