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professional responsibilities duty of neutrality

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do not interfere with a patients personal relationship

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rule of abstinence

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abstain from personal gratification at the patients expense

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fiduciary responsibility

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duty to act in the best interest of the patient entrusted by the patient to provide aid, advice, or protection because of the RNs knowledge and skills. the RN is ultimately responsible for managing boundary issues and is accountable to violations occur

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respect for human dignity

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all people are of inherent worth and should be treated as such. be aware that exams and treatments involving the sexual or private parts of the body can cause trauma to the patient. provide privacy and ensure confidentiality. the RN should provide a professional explanation of the need for each exam, test, and all aspects of care that is given. communicate with the patient in a clear, appropriate, and professional manner

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professional therapeutic relationships

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a professional therapeutic relationship is one that allows health professionals to apply their professional knowledge, skills, abilities, and experience toward meeting the health needs of the patient. trust is the foundation of the relationship

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professional boundaries will:

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set limits for safe relationship with patient based upon their needs, produce consistency and predictability in behavior, define how power is exercised within the therapeutic relationship and allows for a safe connection based on the patients needs, and protect the patient within the relationship

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power differential

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there is an inherent power imbalance in a professional relationship that should be recognized.

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patient vulnerability

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patient is in need of care, may not be able to solve own problems and requires specialized knowledge of the RN, imbalance arises from disclosure by the patient: potential for abuse, may influence the professional's care of this patient, misuse of private info, and use of information to influence patient. access to patient data, RN is in position of authority due to specialized knowledge and RN is in control of the management of patient

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under involvement

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failure to engage in therapeutic relationship

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zone of helpfulness

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in the center of the continuum of professional behavior, appropriate care given to the patient, the majority on interaction occurs in this zone

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over involvement

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most extreme case is sexual misconduct and harm can occur at either end of the continuum

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professional relationships

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nurses are paid to care for patients, time-limited, location defined, goal-directed, nurse, not client responsible for establishing and maintaining professional relationship, nurse has formal knowledge, preparation, and contractual time limits on relationship

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personal relationship

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no payment for being in relationship, no time limits, not location specific, pleasure, interest directed, equal responsibility to establish and maintain relationship, no formal training required, personal choice how much time is spent

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over involvement

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exploitation of the relationship. meeting the nurses needs over the patients needs. not doing what is best for the patient, because he will be angry with you. breach of trust (selling private info to the press). intentional or non-intentional. singular or multiple occurrences. may have benign or harmful effects

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3 types of over involvement

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boundary crossing (most common type), boundary violation (may lead to serious, harmful consequences), and sexual misconduct (rare, representing a small portion of the total number of over-involvement situations)

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boundary crossing

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may be: intentional, inadvertent, thoughtless, or possibly purposeful. brief excursions are crossing the boundaries with a return to established limits of the professional relationship. simple act of kindness or courtesy. the context of the situation must be considered. usually no harmful long-term effects

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examples of boundary crossing

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nurses must use judgment when intentionally crossing boundaries. self-disclosure (personal info), accepting gifts from patients, giving gifts to patients, and appointment changes

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boundary violation

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characterized by: role reversal and secrecy, excessive personal disclosure by the professional (do not discuss personal problems or any aspect of your intimate life with patient), personal rather than professional relationship, and potential for long term effects

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examples of boundary violation

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self disclosure to meet the professionals needs, secrecy for special favors, enmeshed relationships, accepting gifts to meet the professionals needs, and making special accommodations for patient

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professional sexual misconduct

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overt or covert expression of erotic or romantic thoughts/feelings/gestures by a professional toward a patient, that are sexual or may be reasonably construed as sexual, usually intentional, may or may not be benign with boundary violation, long term effects may not be readily apparent (breach of trust)

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the abused patients experience parallels the experience of an incest victim

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like a trusted parent, the professional is trusted to be working only in the patients interest. feelings of betrayal, anger, hurt, violation are all common. embarrassment, may be ashamed to report- feels stupid for trusting then being duped.

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examples of sexual misconduct

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sex without consent (anesthetized patient, use of drugs or hypnosis to diminish ability to resist, forcible sexual assault), statutory rape (children and adolescents), and sex by fraud (sexual gratification disguised as a treatment, unnecessary breast exams, pelvic exams)

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more examples of sexual misconduct

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sneaky sex (frotteurism- sexual gratification from illicit tactile self-stimulation usually acted out in public, voyeurism- sexual gratification from observing others in sexual acts, or undressing), intensely sexual interaction (verbal, fantasy), and sexual harassment (unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of sexual nature

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sexual harassment

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sexual harassment laws apply to all employing and educational institutions. the following situations constitute sexual harassment: when submission is considered a condition of an individuals employment (implicitly or explicitly), when submission to or rejection of conduct is used as the basis for employment decisions affecting the individual, and when such conduct interferes with an individuals work performance or creates an intimidating, hostile, or offensive working environment

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quid pro harassment

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you do something for me and ill do something for you type of exchange

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hostile environment sexual harassment

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when the person is subjected to comments of a sexual nature, offensive sexual materials, or unwelcome physical contact as part of the work environment. reporting to HR is the best place to start. employers may be held liable.

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who is harmed when sexual violations occur?

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professional- helping professions may attract predators, career may be ruined as a result of this problem, and separation from the profession. patient- wide range of responses from embarrassment to depression, even suicide, breach of trust is more harmful than the sexual act itself

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who is harmed when sexual violations occur? cont.

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profession- sexual misconduct cases are high profile and provides negative publicity about the profession, questions how the profession allows this to happen, weakens ethics of care. public- erosion of confidence in the profession may lead to avoidance of interaction with the profession, some states have criminalized the process

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dual relationships

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exists when the nurse interacts with a client in any capacity beyond the role of professional nurse.

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types of dual relationships

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double roles, double professions, double financial relationships, and unavoidable dual relationships

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how do boundary violations happen?

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patient at risk-physical/emotional distress and needs professional services. opportunity- nurses have close personal contact, type of work places the nurse in the patients home, small community involvement outside therapeutic setting. distressed professional- lack of training, situational stress, predators may be drawn to health care professions

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warning signs: excessive self-disclosure

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discussing problems or aspects of intimate life, discussing feelings of sexual attraction to the patient

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secrete behavior

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keeping secrets with the patient, being guarded and defensive when someone questions the interaction

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super nurse behavior

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believing they are the only ones that understand the patient, feels immune from fostering a non-therapeutic relationship

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providing special treatment

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spending a disproportionate amount of time with patient, spending off-duty time, responding to special request regarding meds, food, etc., trading assignments for care of pt, giving gifts and/or special attention

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special attention to nurse by the pt

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dressing up and/or waiting up for nurse, giving gifts, cards, or letters, and testing the boundaries

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special communications

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nurse fails to explain actions, reporting only some aspects of behavior, sending double meanings to questions, tells patient one thing and staff another

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flirtations

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communicating in flirtatious manner, sexual innuendo, off color jokes, seductive dress

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you and me against the world behavior

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nurse views the patient in protective manner, sides with pt

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failure to protect the pt

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poor recognition of sexual attraction, not discussing feelings with supervisor, not transferring care to maintain appropriate behavior, and no respect for pts dignity and privacy

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patients at risk are:

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history of incest or sexual abuse, borderline personality, need to be liked, found attractive, or cared for, difficulty with separation or loss, and multiple personality

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staff at risk: naïve prince or princess: distorted view of helping relationships. Ex:

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graduate nurse who develops a personal relationship with an older adolescent who is terminally ill. the nurse decides to act on the pts desire not to die a virgin

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wounded warrior: yields to temptation, remorseful one-time offender. Ex:

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nurse going through a difficult separation, missing his children and home terribly. he begins to spend extended time with one of his pts leading to intimate sexual contact

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self-serving martyr: neurotic, socially isolated, longstanding problem, over invested in work. Ex:

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a workaholic nurse immersed in the emotional lives of her pts. she develops a personal relationship with a pt that includes giving a loan and progresses to sexual contact

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false lover: impulsive or compulsive sexual harasser. Ex:

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licensed nurse volunteered to assist in a mortuary. he used that opportunity to take photos of genitalia

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dark king or queen: sociopath or narcissistic, self-centered, no concern for harm to others, cunning, intimidating and concealing to cover multiple abuses. Ex:

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nurse is caught having intercourse with an isolated and anesthetized pt in recovery room.

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wild card: psychotic or borderline personality, severely disturbed, poor control. Ex:

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nurse suffering from sever schizophrenia who hears a voice telling her that she can save the male pts by having their babies.

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organizational prevention

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culture of valuing professional ethics, clear policy on boundaries, professional guidelines, thorough screening at time of hire, ongoing staff education, careful supervision, consultation with colleagues

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what if I feel attraction?

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do not act on feelings, don't discuss feelings with pt, discuss feelings with trusted colleague, transfer the care of the pt to another nurse

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what are my limits?

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limit physical contact to that which is therapeutic, limit pt contact to on-duty time, avoid financial dealings, limit self-disclosure to superficial info, avoid making pts problems your own, and understand the context of the situation

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golden rule of boundaries

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do not do or say anything in private or public which cannot be documented in pts record.

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role of the state board of nursing: to protect the public from unsafe nursing practice

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determination of boundaries, taking disciplinary actions against nurses who violate guidelines/ rules, determine whether to separate the nurse from the profession or to rehabilitate the offender

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in summary

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prevention is key, be aware, reflective, and keep pts needs paramount.

Professional Boundaries in Health Care Relationships – Flashcards

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