Professional Boundaries

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Professional Boundaries

• Dianna Spies Sorenson, Ph.D., RN,CNS
• (a portion of this presentation was adapted from
  Diana VanderWoulde 1998)

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Professional Boundaries and Sexual Misconduct

• NCSBN task force
• Review of literature
• Case reviews conducted
• Guidelines and references developed

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What is it?

• Professional misconduct is about power
• Abuse of the nurse-client relationship
• Putting the nurses needs first
• Access to privileged information
• Use influence to meet personal needs I.e. goods,
  comfort, sex
• Breach of trust
• Impedes client development and task accomplishment

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Professional Boundaries

• Represent the balance between the nurses power
  and the clients vulnerability.
• The power of the nurse comes from the
  professional position and the access to private
  knowledge about the client

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Continuum of Professional Behavior
Over-involvement boundary violations
Under-involved cold, distant
Zone of helpfulness
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Establishment of Boundaries - Five Principles
(Simon)

• The rule of abstinence
• The duty to neutrality
• The promotion of client autonomy and self
  determination
• The fiduciary (trust) relationship
• The respect for human dignity

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Five stages of Boundary Infringement

• Stage I - inadvertent crossing
• Stage II - special attention to client
• Stage III - secrecy and special favors
• Stage IV - overt exploitation
• Stage V - sexual misconduct

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Boundary Crossings

• Are brief excursions across boundaries that may
  be inadvertent, thoughtless or even purposeful if
  done to meet a special therapeutic need.

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Boundary Violations

• Can result when there is confusion between the
  prioritization of needs between the nurse and
  client
• Minor (relative) violations are characterized by
  excessive personal disclosure by the nurse,
  secrecy or even reversal of roles
• Major violations include overt damage or
  long-term effects

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Gifts

• Cultural prescriptions
• Degree of boundary violation risk is directly
  proportionate to the monetary value
• May reflect a level of relational extortion

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Family Disclosure

• Private vs. shared information
• Parent/child
• Spousal
• Extended family
• Intent
• Legal vs. ethical responsibilities to report

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Personal Information

• Who, what, when, why, where obtained information
• Voyeurism
• Information to meet personal needs or to help
  patient

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Professional Sexual Misconduct

• Is an extreme form of boundary violation and
  includes any behavior that is seductive, sexually
  demeaning, harassing or reasonably interpreted as
  sexual by the client.
• Professional sexual misconduct is a breach of
  trust

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Professional Sexual Misconduct Categories

• Psychotic or severe borderline personality
• Sociopaths severe narcissistic character
  disorders
• Impulse control disorders
• Severely neurotic /or socially isolated
• Mildly neurotic/situational breakdown in
  otherwise healthy person
• Uninformed/naive

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Warning Signs

• Feelings that the nurse is morally superior
  incapable of violations
• Self-disclosure
• Secretive behavior
• Super nurse
• Special treatment by nurse
• Special attention to nurse

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Warning Signs

• Selective communication
• Flirtations
• You and me against the world
• Nurse fails to take action to protect client

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Role of the Board of Nursing

• Statutory language
• Disciplinary process
• Evaluation by a qualified professional
• Discipline remedies
• Rehabilitation and re-entry
• Prevention

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Statutory Language

• Exercised influence within the nurse-patient
  relationship for the purpose of engaging a
  patient in sexual activity. For the purpose of
  this subdivision, the patient is presumed
  incapable of giving free, full and informed
  consent to sexual activity with the nurse SDCL
  36-9-49(11)

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Statutory Language

• Engaged in gross sexual harassment or sexual
  contact
• SDCL 36-9-49(12)

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Disciplinary Process

• Complaint investigation
• Interview of victim/complaint(s)
• Informal meeting with nurse
• Probable cause determination
• Emergency action, if necessary
• Evaluation
• Final action

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Evaluation

• Well-trained professional qualified in the area
  of boundary violations and sexual misconduct
• Authority to mandate a mental health, chemical
  dependency or physical examination upon
  determination of probable cause (SDCL 36-9-49,1)

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Discipline Remedies

• For justice
• To reinforce a standard or underline the
  seriousness of the offense
• To deter the offender from repeating the offense
• To deter others from committing the same offense

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Rehabilitation and Re-entry

• Must admit guilt
• Express remorse
• Indicate a strong desire to change
• Goal is to bring about change in the individual
  so that he/she will be able to return to practice
  without the public being at risk

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Two Questions for Evaluators

• To a reasonable degree of psychological
  certainty, have the goals set for the
  rehabilitation been attained?
• Would you have any qualms whatsoever of having
  your family member receive care from the provider?

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Evaluation of a Boundary Crossing

• What was the intent of the crossing?
• Was it for a therapeutic purpose?
• Was it in the clients best interest?
• Did the student demonstrate self-awareness?
• Did the student consult with an instructor, staff
  or supervisor?
• Was the incident appropriately documented?

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Response to Patient Advances

• Clarify the students role
• Set appropriate verbal boundaries
• Set physical boundaries
• Consult instructor/supervisor
• Document interactions as directed.
• Seek additional support
• Treat patient respectfully and redirect

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Prevention

• Nursing faculty
• Nurse employers
• Nursing students and licensed nurses

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Prevention of Boundary Crossings

• Be aware of any feeling of attraction and discuss
  with supervisor or trusted colleague
• Transfer care of patient to another nurse
• Be alert to signs that a patient may be
  interested in or encouraging a non-professional
  relationship

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Prevention of Violations

• Respect patients dignity privacy at all times
• Provide professional explanations for
  examinations, procedures, tests, care
• Clear, appropriate, professional communication
• Never engage in flirtatious communication,
  off-color or sexual innuendo jokes or offensive
  language
• Dont discuss personal problems, or any aspect of
  intimate life with patients

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Prevention of Violations

• Delineate the care plan with clear,
  scientifically grounded rationale for
  interventions
• Review care outcomes if progress is not noted,
  then question the interventions and need for
  continued care
• Clarify whose needs are met through care and
  interventions
• Offer support without judgment
• Correctly identify problematic client backgrounds

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Client/Nurse Risk Factors

• Known history of child abuse
• Severely disturbed
• Psychiatric/chemical dependency settings
• Chronic care needs
• Difficulty/inability to determine appropriate
  boundaries (e.g. ACOA, co-dependency, BPD,etc)
• Situations that reduce client resources to make
  decisions (physical, spiritual, emotional,
  financial, social, time, etc)