Wednesday, March 02, 2005

Professional Boundaries - Part II

In my last post, I listed several actions that may or may not be viewed as a breach of professional boundaries. I then asked for people's opinions of the described actions - were they in fact breaking boundaries?

I expected a slightly more lively debate than what appeared in the comments. People seemed frightened off by the first two people who said they were all breaking boundaries.

The truth of the matter is, when you read about professional boundaries, you almost never get a list of "yes, this is okay" and "no, this is not okay." The reason for this is because boundaries are not always black and white. Anyone who has experience in hospice, oncology (cancer care), or psychiatry is probably more likely to be aware of the lack of a clear line than in most other fields.

First of all, the basic principle to keep in mind when contemplating boundaries is the fact that nurses have more power in nurse-patient relationships than patients do. Therefore, much like with a teacher-student relationship, effort must be made not to violate that power. This makes developing romantic relationships between health care providers and their patients clearly a breach in the boundary. This is the most clear boundary - I would even say the only boundary that is that crystal clear.

Another set of questions to ask yourself when in situations that make you feel concerned that you may be breaking a boundary:

-Who is benefitting most from this action?
-What do I stand to gain from this action?
-How will this patient feel if the next nurse/chaplain/health care provider does not do the same for me/treat me the same? Should they expect the same treatment from everyone?

It is understandably human nature that in certain circumstances, a level of kinship develops when nurses and patients work together for longer periods of time than normal. If you normally see a patient for a week before they're discharged from the hospital, then one patient has stayed for a month, a different type of rapport will likely be established.

This same can hold true for nurses who work with patients dealing with major existential issues - such as patients who are dying and patients who have an acute life-threatening illness.

In these cases, however, special care needs to be taken. The boundaries may blur some, however, one must maintain some boundaries so as not to get burnt out and quit your job because you're constantly overextending yourself. Maintaining boundaries can be especially difficult in these professions. Partly because of the nature of the work and partly because of the personalities of the people whom tend to be drawn to this type of work.

Boundaries must also be reviewed on a case-by-case basis. For some cultures, sitting on the edge of the bed may be viewed as disrespectful. However, for other cultures and for patients grappling with life or death issues, sitting on the edge of the bed for a minute may provide more comfort than standing over their bed for 15 minutes. Of course, always ask for permission first. Never assume anything about people's comfort level based on culture alone. And for some nurses, sitting on the edge of the bed may never be acceptable. I, personally, tend to squat down to put myself at eye level with patients who are particularly upset rather than sit on the bed. Though I have sat on one or two beds in my career thus far.

Finally, keep in mind that once a boundary has been broken, it is nearly impossible to restore it. If you've given the patient your home phone number while you are out of town, don't expect them to stop using it once you're back to work. And don't make promises that you can't keep. If you tell the patient that you will visit them in their new facility, the boundary has already been broken.

Condolance cards are a tricky one. While they are strongly encouraged by most palliative care and hospice organizations, copying any information out of a patient's chart is breaking a law called HIPAA, which states that health care providers may receive information about each patient only as needed to treat that patient. A condolance card does not necessarily fall under "treatment," though I suppose one might argue it falls under treating the family's grief.

I hope I've illustrated how grey boundaries can be. Some people may disagree with me, as well.

For more information, to help you make your own decisions about professional boundaries, I've compiled a list of websites that provide valuable insight into determining whether or not someone is breaking a boundary. Unfortunately, I don't have the list on me as I write today. But I will post it later, as an addendum to this same post for those who are interested.

Thanks so much to everyone who provided comments in the last post. I hope you found the exercise useful.

--More on Professional Boundaries--

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