Professional boundaries – staying safe in the professional role

Dr Wendy H McIntosh PhDRGN, Grad. Dip. MH, MN

1 CNE PointsContinuing Nurse Education Pointsas part of Royal College of Nursing, AustraliaLifelong Learning Program (3LP)

This session has been Endorsed by APEC No. 060210229 as Authorised by Royal College of Nursing, Australia according to approved criteria.Royal College of Nursing Australia recommends that nurses should aim to achieve 20 CNE points per year.

A brief intro.....

...and so to the session

Objectives

• Definitions – common language• Boundary Framework – (context, categories of concern)

• Where on the line am I?• Identify warning signs• Discuss reasons why boundary crossing/violations occur

• Intrapersonal, interpersonal & systemic• Have increased awareness about own and others

behaviours in relation to professional boundaries• Identify strategies for managing professional boundary

issues (self, colleagues, organisation)

and....

Stimulate discussion, curiosity, understanding

Self assessment• Sending patient a postcard whilst you are on holiday• Sexual involvement with client• Using clients for business dealings• Developing friendships with clients• Making sexual innuendoes• Not documenting relevant information in patients charts• Giving a patient who is crying a hug• Calling the patient darling, pet, etc• Promising patient that you will visit them in hospital in your own time (and visiting them)• Phoning the patient at home to make sure they are “okay” following discharge from hospital (not required as part of professional role)(Gutheil & Gubbard, 1993; Peternelj-aylor, 2002)

Reasons for becoming a nurse?

What guides your professional boundaries?

Personal beliefsFamily beliefsCommunity beliefsReligious beliefsProfessional requirementsOrganisational requirementsDesignated professional role

Doel, et al (2010) reported that:• formal research played little part in guiding individuals to assist them identify professional boundaries• only 10-15% of the participants made regular reference to regulatory and professional codes of practice

The clashLack of appreciation or understanding of the ANMC:Code of EthicsCode of Professional ConductCompetency StandardsNurses guide to professional boundariesHow recently have you referred to these to guide your practice?

Difficulty setting clear limits / boundaries (do not want to disappoint, upset or let others down)Professional slips into the personal – in an interaction the dynamicis not nurse and patient…..it is father and child or granddaughter/GrandmotherStruggle with conflict

Personal issues

• Illness (physical / mental illness)• drug & / or alcohol related issues • family / relationship dynamics• lack of awareness (education/ training)• need for control

(Jones, 2004; Peternelj, 2002; Nursing Review April, 2006:3)

The support

Consistently refers to Codes and seeks guidance / counselwhen unsure

Feels comfortable with setting limits / saying no (tone of voiceand body posture important)

Recognizes that there is a professional job to do (professionalfriendliness is different from developing a friendship)

Appreciates that the therapeutic relationship is not just 1:1 (involves many other stakeholders including the regulatory body…..thus multiple professionalrelationships)

Professional boundaries - limits that protect the space between the professional's power and the client’s vulnerability.

Definitions

Boundary crossings - brief excursions across boundaries that may be inadvertent, thoughtless or even purposeful if done to meet a special therapeutic need

Boundary violations - can result when there is confusion between the needs of the nurse and those of the client

(A nurses guide to professional boundaries, ANMC 2010)

The boundary framework

Over involved Under involvedSafeTherapeutic

Relations

(A nurses guide to professional boundaries, ANMC 2010)

• therapeutic relationships• access to / disclosure of information• gifts / services and financial relationships• dual relationships(ANMC, 2010)

Four categories of concern

The boundary framework

Over involved Under involvedSafeTherapeutic

Relations

(A nurses guide to professional boundaries, ANMC 2010)

CONTEXT

What is the intent?

Whose needs are being met?(consider physical, emotional, psychological, spiritual, sexualsocial, financial, services)

If the answer is …the needs of the health professional ….then a transgression has occurredNext questions ………is it a crossing or violation? is it over or under involved?

Warning signs

Warning signs – over involvement• Frequently thinking of client

when away from work• Frequently planning another

clients care around the clients needs

• Sharing personal information or work concerns with the client

• Feeling worried about the clients or family’s view of the nurse as a person if their expectations are not met

Wilson & Winslow (2002)

• Feeling responsible for clients lack of progress

• Feeling unusually irrational if someone or something in the system creates a barrier or delay in the clients progress

• Noticing more physical touching than is appropriate or required

• Feeling a sense of excitement or longing for client

• Making special exceptions for client because they are well connected, appealing, impressive

Warning signs – under involvement

• Disinterest in client

• Disengagement from client

• Continually asking colleagues to care for the client (not a clinically based request)

• Ignoring clients requests

• Talking about patient in derogatory manner with colleagues, with other patients

Transference & countertransference

Transference is an unconscious process in which the patient experiences feelings and attitudes toward staff that were originally associated with significant others earlier or more recently in life (may be unmet wishes, unresolved conflicts)

“This nurse cares about me”“This nurse is just like my mother, she didn’t care about me either”

Counter transference - the transference applied to staff. Staff may be at times genuinely angry, worried, caring about a patient or their actions, however counter transference is where the responses are not justified in the context of the situation. (Jones, 2004)

“why doesn’t this patient just do what I ask them to do”

• Do I dread having to interact with this patient?

• Do I look forward to my interaction with this patient?

• Am I bored with the patient and feel we are not progressing?

• Am I afraid of the patient?

• Are there patients I actively avoid?

• Do I want to protect, reject or punish the patient?

• Do I get extreme pleasure out of seeing the patient?

• Am I impressed by or trying to impress the patient?

• Does the patient make me very angry and frustrated?

Helpful questions for reflection

Guiding principles

• Health professional is responsible to delineate and maintain boundaries

• Health professional needs to work within the boundaries of the therapeutic relationship

• Health professional needs to be aware of and examine any boundary crossing/violation

• Different contexts (care setting, community influences, client needs and the nature of therapy) affect boundary delineation

(Campbell, Yonge & Austin, 2005; Gutheil, 2005)

Davaar Consultancy – Learning with integrity, passion & fun

Professional boundaries

In place to safe guard…– the patients– colleagues– and YOU

Any questions?

References• ANMC (2010) A nurses guide to

professional boundaries• Campbel, R. J., Yonge, O., & Austin, W.

(2005). Intimacy Boundaries Between Mental Health Nurses & Psychiatric Patients. Journal of Psychosocial Nursing, 43, 5, 33-39.

• Doel, M., Allmark, P., Conway, P., C Dowburn. M., Flynn. M., Nelson. P., &

Tod. A. (2010). Professional boundaries: c

rossing a line or entering the shadows? British Journal of Social Work, 40, 1866- 1889.• Everett, B., & Gallop, R. (2001). The link

between childhood trauma and mental illness. Thousand Oaks California: Sage.

• Gutheil, T. G. (2005). Boundary Issues and Personality Disorders. Journal of Psychiatric Practice, 11 (2), 88-96.

• Gutheil, T.G., & Gabbard, G. O. (1993). The concept of boundaries in clinical practice: Theoretical and risk management dimensions. American Journal of Psychiatry, 150, 188-196.

• QNC Guidelines for Registered Nurses and Enrolled Nurses regarding the Boundaries of Professional Practice (1999). Developed by the University of Newcastle Australia and NSW Nurses Registration Board.

Davaar Consultancy – Learning with integrity, passion & fun

References cont........

• McIntosh, W.H. (2006). Professional boundaries in the clinical setting. Nursing Review, Oct.10-11.

• Peternejl-Taylor, C. (2002). Journal of Psychosocial Nursing, 40 (4), 23-29

• Nursing Review, April (2006) Victorian service to help nurses overcome addiction. April Edition: pg 3

• Wilson, B., & Winslow, W. (2002). Professional Boundaries. Nursing BC. 18

Next 2 day workshop on Professional Boundaries:

Date: Nov 3rd & 4th, 2011Venue: Davaar Consultancy 184 Patrick Street, Laidley, Qld. 4341

Download flyer from website:www.davaar.com.au

Resources

Want to access our new internet training tool on professional boundaries ?go to http://training.davaar.com.au/

Contact us: wendy@davaar.com.auWeb: www.davaar.com.auMobile: 0411 385 573