Week 10: Establishing, Maintaining, Navigating Boundaries in the Therapeutic Relationship

Boundary

Indicates what is out of bounds in a relationship — acts to constrain, constrict, limit

…define the limits of the professional role

CNO Guidelines re: boundaries (4)

Abstinence
Neutrality
Autonomy
Putting best interest of client first

What are the 2 purposes of boundaries?

Protecting clients from harm
Protecting the nurse/professional (wellbeing, misconduct reprimands, civil litigation)

What is the boundary triad — PORTER

BASE — Nurse (supports both sides, duty to pt + society re: upholding professional boundaries)

R-SIDE — Patient in vulnerable state

L SIDE — Society (professional boundaries)

Professional boundaries — PORTER

rigid vs. loose/unclear?

dynamic, constantly changing dt diff influences

if boundary too rigid → nurse looses flexibility & effectiveness

if boundary too loose/unclear → blurs nurse's role + undermines professionalism

6 factors affecting boundaries

1. Pt needs & personality

2. HCP character & training

3. Status of treatment alliance (diff w/ palliative vs. post-op pt)

4. treatment Setting (home vs. hospital)

5. Geography (dual relationships in rural)

6. Culture (acceptance of gifts)

dual relationships

caring for someone you know w/in the community not just as pt (common in rural)

document if it has to happen

can chat w/ them if THEY approach you in public but AVOID any convo about HC/PHI

boundary drift

nurse hasn't crossed boundary in therapeutic relationship but is close to (thinks ab crossing it)

…daydream, fantasize, considers crossing the line = increases risk of it happening

boundary crossings

exercusions across the lines demartacting the professional relationship

Eg: taking the client to the cafeteria, favoritism

per CNO:
HCP misusing the power in the relationship to meet their personal needs rather than pt’s OR behaving in an unprofessional manner w/ the pt — intentional OR unintentional

when may a traditional boundary crossing be appropriate?

therapeutic reason for doing it, i.e., written in pt care plan → rationale must be documented

Eg: better chance of PHN maintaining confidentiality of IPV pt if don’t meet at home

boundary violations

crossing of the line that is clearly HARMFUL or EXPLOITIVE → causes harm to pt

…puts the HCP’s needs ahead of the pt’s

…puts the pt, the nurse, and the therapy at risk

boundary crossing vs. violation — PORTER

boundary crossing is NOT harmful / exploitive and may have a therapeutic purpose

…Eg: going on walk w/ pt who is uncomfortable in an office setting

Examples of boundary violation

sexual + non sexual misconduct/relationships
giving + receiving gifts
financial incentives
conflict of interests
improper touch
improper social involvement

DISCUSSING FAMOUS PTs

slippery slope argument (3)

…metaphorical descent from ethical to unethical

…course of action that seems to inevitably lead from one action/result to another w/ unintended consequences

…crossing a boundary in progressively deeper ways

…Eg: disclosing some personal info w/ pts → lines become blurry → start of slippery slope

progression of slippery slope argument

action w/ control → grey area → loss of control → unintended outcome

Slippery Slope — per AUSTIN

HCPs slide from small personal acts that are not strictly therapeutic (share some personal info w/ pt) → to more serious transgressions (becoming romantically incovled). involved

How do HCP boundary violations re: sexual encounters w/ pts begin? — AUSTIN

the move toward sexual encounter often begins w/ some level of personal self-disclosure

working outside professional boundaries leads to (4) — PORTER

ambiguity → reduces effectiveness of HCP

undermines independent nursing judgement

exploitation of pt → nurse in position of power

confusion

potential sources of boundary violation reprimands?

CNO discipline
civil litigation
employer discipline

How are nurses held accountable for crossing boundaries by their regulatory body?

Disciplinary decisions are made by CNO against nurse who has crossed boundaries

…CNO publishes decisions of hearings held by disciplinary committee on website

who can watch CNO discipline hearings?

open to public via live video call → – anyone can attend = CNO accountability to public

WHAT TO DO if you're a nurse who suspects a colleague is engaging in sexual behavior w/ a pt?

LEGALLY OBLIGATED to report suspected sexual behavior w/ pt by another CNO member to the college immediately!!!!

How might a nurse be held accountable if they were violating a boundary by sexually engaging w/ pt BUT resigned from job/CNO?

YES → if any legal repercussions

NO → avoid disciplinary action from regulatory body by resigning from CNO & employer

CNO guidelines re: relationship after therapeutic relationship has been terminated

ONLY after 365 days

…may, after one year, engage in a personal friendship, romantic/sexual relationship w/ a pt (OR pts significant other) ONLY after deciding that such a relationship would not have negative impact on the pt or other pts’ well-being + less likelihood of the pt requiring ongoing care/readmission

AUSTIN — metaphor ab boundaries as wall? highway? bridge? neutral zone?

WALL — ethical boundaries entirely b/o external constraints (rules governing profession)

• RIGID WALLS keep nurses in & pts out

• ethical considerations must come from w/in ethical relationships + indv values

HIGHWAY – consistent driving rules keep you + others on the road safe

• Pt on healthcare journey → rules protect pt, nurse, profession + ensure safe passage for all

BRIDGE – connection b/w nurse & pt = NECESSARY

• Moral task when building bridge = shared understanding b/w nurse/pt

TERRITORY/ NEUTRAL ZONE – early FNMI in Canada had no firm boundaries b/w different tribal lands → territory in b/w = protected, neutral space where both tribes could travel while mindful/aware they were not on own land

• Safe space available to both, but belonged to neither where all behaved respectfully

• Emphasizes awareness of others' rights + need for diligence & attentiveness to own actions

PORTER — What to consider when deciding whether to cross a boundary?

• who does it benefit

• are coercive/exploitive element present

• does it rise to professional ideals

• ask others for opinions (nursing admin for permission to do it)
  

**if not comfortable talking about it → indication that you shouldn't be doing it

3 elements critical to avoiding boundary violations — PORTER

analysis

self-reflection

awareness