Transcript Professional boundaries

Professional Boundaries
FIONA BERGIN MD LLM MED
DALHOUSIE UNIVERSITY
OCTOBER 2013
Objectives
To understand and appreciate:
what boundary transgressions are
why they occur
the concerns they raise
how they may be avoided/managed and
how they may negatively impact on patient care.
Boundary Transgressions
Boundary crossings
Boundary violations
Who transgresses?
 Patients, families, health care providers
Who is responsible for avoiding transgressions and
maintaining boundaries?
 Health care providers
Examples of boundary transgressions
Being overly familiar, making personal disclosures
Verbal or physical abuse, disruptive behaviours
Sexual impropriety, sexual harassment
Gift-giving or receiving
Engaging in dual or multiple relationships
Treating those who are not clients/patients
Boundary Crossings
“less severe departures” from professional practice
(Brooks, 2012)
often resulting from good intentions
“may actually facilitate patient care”,
“ are more common and appropriately used in some
specialties” or disciplines
Often precede boundary violations (esp sexual
violations)
You’re Special and So Am I:
“Special” Patients and Clients
Exceptions made for some clients, usual practices
not followed.
We feel good because we are doing something extra
for them and they are so grateful.
But
We may be enabling the boundary crossings.
By the time we realize it, it can be difficult to retreat
to a neutral position. (Gutheil,2005)
Self-Reflection
 Is this what I am trained to do?
 Is this part of my job?
 Do I do this for all patients/clients?
 If I do this, what are the risks/benefits to me, my
client, our therapeutic relationship, my
relationship with other clients and my profession ?
Dealing with Boundary Crossings
 Ignore
 Document
 Talk to client/patient/colleague about their
behaviours
 Talk to colleagues for guidance/validation/support/
Boundary Violations
 “the exploitation of power in the professional
relationship…when [health care professionals] use
their position of trust and authority for their own
pleasure or benefit (or for the benefit of others).”
(Brooks, 2012)
 Abuse in any form (verbal, physical, sexual,
financial)
 Other than the perpetrator, most agree it is
unprofessional behaviour
Prevention of Boundary Violations
 Avoid boundary crossings- evidence shows crossings
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usually precede violations esp in case of sexual
violations (Brooks,2012)
Address personal risk factors in both parties
Self-reflection and self-monitoring
Abide by professional policies and codes of ethics
Listen to advice given by others
Why do they occur?
 HCP wellness issues (esp mental health issues)
 HCP personal stressors (relationship, financial,
workplace)
 Patient characteristics- needy or demanding
 Relationship factors- longer-term relationship, type
of care provided (counselling)
 Context- dual/multiple relationships, location (rural
vs urban), availability of other resources
Treating Non-Patients
 Joan, RN, is caring for her mother with terminal
breast cancer and administering all her
medications including her morphine since other
family members are uncomfortable doing so.
 Mary, MD, is approached by her colleague to write
him a prescription for his hypertension meds as he
is going on vacation tomorrow and can’t get in to
see his own FD. This is the second time this year he
has asked Mary to do this.
Treating Friends and Family
 Am I trained to meet their medical needs?
 Am I too close to probe their intimate history?
 Can I deliver bad news?
 Can I be objective enough to not give too much, too
little or inappropriate care?
 How is my involvement with their healthcare going
to be viewed by other family members? Will I be
blamed for decisions made or bad outcomes?
 Will compliance with treatment be an issue if I am
the provider rather than an unrelated HCP?
 Will I undermine the efforts of other HCPs to treat
my loved one?
 Can I justify my treatment or involvement in care to
impartial individuals? To my peers? (LaPuma,1992)
Gift-Giving
You are a nurse on the pediatric oncology ward looking
after Timmy. It was his birthday today and you gave
him a toy you purchased and made him a cake because
his parents were unable to be with him today and you
know they can’t afford to buy him toys.
Gift-Receiving
You are a community mental health nurse and check
in every few months on a frail elderly couple because
they have diabetes and are too frail to get to the clinic
for regular checks. During each visit, they invite you to
have tea. They tell you they are moving into a nursing
home and give you a tea cup and saucer because they
can’t take all their belongings with them and it was the
tea cup you always drank your tea from.
Gift-Giving
 What is the intention of the giver? Are there
inappropriate expectations/obligations being
created?
 What will be the effect on the therapeutic
relationship of accepting or rejecting the gift? on
other relationships?
 What is the value of the gift to the giver? To the
receiver? What is its monetary value?
 Are you comfortable with others knowing what has
been given/received?
Self-Disclosure
 In initial visits, 1/3 of physicians made self
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disclosures.
None of the physician self-disclosures were patientfocused, seldom in response to a patient’s inquiry.
Only 4% were considered useful to patients
11% were considered to be disruptive
Recommendation- physicians might try expressions
of empathy, understanding and compassion instead.
(McDaniel, 2007)
Why Are you Telling Your Story?
Are you trying to make your patient comfortable?
Are you trying to make yourself comfortable?
Are you disclosing personal information to impress
your client ?
Are you seeking advice or support from your patient?
Dual/Multiple Relationships
A multiple or dual relationship exists when in addition
to the therapeutic relationship between the HCP and
client/patient, there exists “a significantly different
relationship, such as a social, financial, or professional
role with that client”(Campbell, 2003)
 The American Psychologists Association expands the
definition to include “a relationship with a person
closely associated with or related to the
client/patient” or “promises to enter into” another
relationship with either in the future. (APA Ethical
Principles of Psychologists and Code of Conduct
Including 2010 Amendments )
Multiple Relationships
 More likely to arise when HCPs live and work in the
same community, especially in smaller communities
and where there are fewer health care providers to
provide the needed services.
 The “helper role” within social work may promote
the development of dual relationships
 Distinctions often made between personal
relationships which become professional and
professional relationships which become personal.
Dual Relationships
Advantages
Ability to place their patients’ health within the context
of their broader lives
Improves trust and rapport
Disadvantages
Social isolation (if restricts them)
Learning more about friends than wish to
Being approached for medical advice outside of the
office
Assessing the Risks in Dual Relationships
Exploitation of patient/client
Loss of therapist objectivity
Harm to the professional relationship.
(Clark, 2003)
Managing Dual and Multiple Relationships
 Psychologists are advised to “refrain from entering
into a multiple relationship if the multiple
relationship could reasonably be expected to impair
the psychologist’s objectivity, competence or
effectiveness in performing his or her functions as a
psychologist or otherwise risks exploitation or harm
to the person with whom the professional
relationship exists.”(Ethical Principles, s. 3.05(a)
 Otherwise, the relationship is not unethical.
Managing Dual Relationships
Avoidance
Live in different community
Compartmentalize different roles
Refer when uncomfortable providing care
(or aspects of care)
Setting boundaries as to where/when
medical advice will be given (Brooks, 2012)
Attitudes Towards Boundaries with Patients
 Study (Regan, 2010)asked MDs about their views re
acceptability of several interactions with patients:
 Having social interactions
 Having business dealings
 Having sexual relations
 The more permissive the physician’s views, the less
likely they supported peer evaluation, reporting of
medical errors and provision of care to those who
could not pay
 Stricter views were held by women, non-whites and
foreign medical school graduates
Abuse of HCPs by Patients
 HCPs are at greater risk of workplace abuse than
most other workers
 Family physicians and nurses most at risk of abusive
encounters with patients .
 Also those working in EDs, walk-in clinics, with
patients suffering from mental illness or addictions
at higher risk
 Those physicians who are younger, female, and
working in rural locations are more likely to
experience abuse and harassment (Miedema, 2009)
Abuse by Colleagues
Professional boundaries are not being respected when
health care providers engage in disrespectful,
harassing or disruptive behaviours with each other.
These behaviours do not promote collegiality among
health care team members and lead to poor team
functioning.(Leape,2012)
Impact on patient care
Poor team functioning leads to poor patient care.
67% linked disruptive behaviours with adverse events
for patients
71% linked disruptive behaviours with medical errors
27% linked disruptive behaviours with patient
mortality (Rosenstein, 2008)
Presenting
A Sad Tale: A Critique of
Boundaries Blurred
The (Unhappy) End
Thanks for your attention and participation.
[email protected]
Useful links
https://crnbc.ca/Standards/PracticeStandards/Pages/bou
ndaries
http://www.socialworker.com/jswve