Professional boundaries – staying safe
in the professional role
Dr Wendy H McIntosh PhD
RGN, Grad. Dip. MH, MN
1 CNE Points
Continuing Nurse Education Points
as part of Royal College of Nursing, Australia
Lifelong 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 beliefs
Family beliefs
Community beliefs
Religious beliefs
Professional requirements
Organisational requirements
Designated 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 clash
Lack of appreciation or understanding of the ANMC:
Code of Ethics
Code of Professional Conduct
Competency Standards
Nurses guide to professional boundaries
How 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 dynamic
is not nurse and patient…..it is father and child or granddaughter/
Grandmother
Struggle 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 / counsel
when unsure
Feels comfortable with setting limits / saying no (tone of voice
and body posture important)
Recognizes that there is a professional job to do (professional
friendliness 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 professional
relationships)
Definitions
Professional boundaries - limits that protect the
space between the professional's power and the
client’s vulnerability.
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
Safe
Therapeutic
Relations
Under involved
(A nurses guide to professional boundaries, ANMC 2010)
Four categories of
concern
• therapeutic relationships
• access to / disclosure of information
• gifts / services and financial
relationships
• dual relationships
(ANMC, 2010)
The boundary framework
•
.
Over involved
Safe
Therapeutic
Relations
Under involved
CONTEXT
(A nurses guide to professional boundaries, ANMC 2010)
What is the intent?
Whose needs are being met?
(consider physical, emotional, psychological, spiritual, sexual
social, financial, services)
If the answer is …the needs of the health professional ….then a
transgression has occurred
Next 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”
Helpful questions for reflection
• 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?
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, 18661889.
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, 2011
Venue: 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.au
Web: www.davaar.com.au
Mobile: 0411 385 573