Fiona Bergin MD LLM MEd - PowerPoint Presentation

Slide1

Fiona Bergin MD LLM MEdDalhousie UniversityOctober 2013

Professional BoundariesSlide2

Objectives

To understand and appreciate:

what boundary transgressions are

why they occur

the concerns they raise

how they may be avoided/managed and

how they may negatively impact on patient care. Slide3

Boundary Transgressions

Boundary crossings

Boundary violations

Who transgresses?

Patients, families, health care providers

Who is responsible for avoiding transgressions and maintaining boundaries?

Health care providersSlide4

Examples of boundary transgressions

Being overly familiar, making personal disclosures

Verbal or physical abuse, disruptive behaviours

Sexual impropriety, sexual harassment

Gift-giving or receiving

Engaging in dual or multiple relationships

Treating

those who are not clients/patients Slide5

Boundary Crossings

“less severe departures” from professional practice (Brooks, 2012)

often resulting from good intentions

“may actually facilitate patient care”,

“ are more common and appropriately used in some specialties” or disciplines

Often precede boundary violations (

esp

sexual violations) Slide6

You’re Special and So Am I:“Special” Patients and Clients

Exceptions made for some clients, usual practices not followed.

We feel good because we are doing something extra for them and they are

so

grateful.

But

We may be enabling the boundary crossings.By the time we realize it, it can be difficult to retreat to a neutral position. (Gutheil,2005)Slide7

Self-Reflection

Is this what I am trained to do?

Is this part of my job?

Do I do this for all patients/clients?

If

I

do this, what are the risks/benefits to

me, my client, our therapeutic relationship, my relationship with other clients and my profession ?Slide8

Dealing with Boundary Crossings

Ignore

Document

Talk to client/patient/colleague about their behaviours

Talk to colleagues for guidance/validation/support/Slide9

Boundary Violations

“the exploitation of power in the professional relationship…when [health care professionals] use their position of trust and authority for their own pleasure or benefit (or for the benefit of others).” (Brooks, 2012)

Abuse in any form (verbal, physical, sexual, financial)

Other than the perpetrator, most agree it is unprofessional behaviourSlide10

Prevention of Boundary Violations

Avoid boundary crossings- evidence shows crossings usually precede violations

esp

in case of sexual violations (Brooks,2012)

Address personal risk factors in both parties

Self-reflection and self-monitoring

Abide by professional policies and codes of ethics

Listen to advice given by othersSlide11

Why do they occur?

HCP wellness issues (

esp

mental health issues)

HCP personal stressors (relationship, financial, workplace)

Patient characteristics- needy or demanding

Relationship factors- longer-term relationship, type of care provided (counselling)

Context- dual/multiple relationships, location (rural vs urban), availability of other resourcesSlide12

Treating Non-Patients

Joan, RN, is caring for her mother with terminal breast cancer and administering all her medications including her morphine since other family members are uncomfortable doing so.

Mary, MD, is approached by her colleague to write him a prescription for his hypertension meds as he is going on vacation tomorrow and can’t get in to see his own FD. This is the second time this year he has asked Mary to do this. Slide13

Treating Friends and Family

Am I trained to meet their medical needs?

Am I too close to probe their intimate history?

Can I deliver bad news?

Can I be objective enough to not give too much, too little or inappropriate care?

How is my involvement with their healthcare going to be viewed by other family members? Will I be blamed for decisions made or bad outcomes?Slide14

Will compliance with treatment be an issue if I am the provider rather than an unrelated HCP?

Will I undermine the efforts of other HCPs to treat my loved one?

Can I justify my treatment or involvement in care to impartial individuals? To my peers? (LaPuma,1992)Slide15

Gift-Giving

You are a nurse on the pediatric oncology ward looking after Timmy. It was his birthday today and you gave him a toy you purchased and made him a cake because his parents were unable to be with him today and you know they can’t afford to buy him toys.Slide16

Gift-Receiving

You are a community mental health nurse and check in every few months on a frail elderly couple because they have diabetes and are too frail to get to the clinic for regular checks. During each visit, they invite you to have tea. They tell you they are moving into a nursing home and give you a tea cup and saucer because they can’t take all their belongings with them and it was the tea cup you always drank your tea from. Slide17

Gift-Giving

What is the intention of the giver? Are there inappropriate expectations/obligations being created?

What will be the effect

on the therapeutic relationship of

accepting or rejecting

the gift?

on

other relationships?What is the value of the gift to the giver? To the receiver? What is its monetary value?Are you comfortable with others knowing what has been given/received?Slide18

Self-Disclosure

In initial visits, 1/3 of physicians made self-disclosures.

None of the physician self-disclosures were patient-focused, seldom in response to a patient’s inquiry.

Only 4% were considered useful to patients

11% were considered to be disruptive

Recommendation- physicians might try expressions of empathy, understanding and compassion instead. (McDaniel, 2007)Slide19

Why Are you Telling Your Story?

Are you trying to make your patient comfortable?

Are you trying to make yourself comfortable?

Are you disclosing personal information to impress your client ?

Are you seeking advice or support from your patient?Slide20

Dual/Multiple Relationships

A multiple or dual relationship exists when in addition to the therapeutic relationship between the HCP and client/patient, there exists “a significantly different relationship, such as a social, financial, or professional role with that client”(Campbell, 2003)

Slide21

The American Psychologists Association

expands

the definition

to include “a relationship with a person closely associated with or related to the

client/patient” or

“promises to enter into” another relationship with either in the future

. (

APA Ethical Principles of Psychologists and Code of Conduct Including 2010 Amendments )Slide22

Multiple Relationships

More likely to arise when HCPs live and work in the same community, especially in smaller communities and where there are fewer health care providers to provide the needed services

.

The “helper role” within social work may promote the development of dual relationships

Distinctions

often made between personal relationships which become professional and professional relationships which become personal. Slide23

Dual Relationships

Advantages

Ability to place their patients’ health within the context of their broader lives

Improves trust and rapport

Disadvantages

Social isolation (if restricts them)

Learning more about friends than wish toBeing approached for medical advice outside of the office Slide24

Assessing the Risks in Dual Relationships

Exploitation

of

patient/client

Loss

of therapist

objectivity

Harm to the professional relationship. (Clark, 2003) Slide25

Managing Dual and Multiple Relationships

Psychologists are advised to “refrain from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence or effectiveness in performing his or her functions as a psychologist or otherwise risks exploitation or harm to the person with whom the professional relationship exists.”(

Ethical Principles, s. 3.05(a)

Otherwise, the relationship is not unethical. Slide26

Managing Dual Relationships

Avoidance

Live in different community

Compartmentalize different roles

Refer when uncomfortable providing care (or aspects of care)

Setting boundaries as to where/when medical advice will be given (Brooks, 2012)Slide27

Attitudes Towards Boundaries with Patients

Study (Regan, 2010)asked MDs about their views re acceptability of several interactions with patients:

Having social interactions

Having business dealings

Having sexual relationsSlide28

The more permissive the physician’s views, the less likely they supported peer evaluation, reporting of medical errors and provision of care to those who could not pay

Stricter views were held by women, non-whites and foreign medical school graduatesSlide29

Abuse of HCPs by Patients

HCPs are at greater risk of workplace abuse than most other workers

Family physicians and nurses most at risk of abusive encounters with patients

.

Also those

working in EDs, walk-in clinics, with patients suffering from mental illness or addictions

at higher risk

Those physicians who are younger, female, and working in rural locations are more likely to experience abuse and harassment (Miedema, 2009)Slide30

Abuse by Colleagues

Professional boundaries are not being respected when health care providers engage in disrespectful, harassing or disruptive behaviours with each other.

These behaviours do not promote collegiality among health care team members and lead to poor team functioning.(Leape,2012)

Slide31

Impact on patient care

Poor team functioning leads to poor patient care.

67% linked disruptive behaviours with adverse events for patients

71% linked disruptive behaviours with medical errors

27% linked disruptive behaviours with patient mortality (Rosenstein, 2008)Slide32

Presenting

A

Sad Tale: A Critique of

Boundaries Blurred

The (Unhappy) EndSlide33

Thanks for your attention and participation.

fiona.bergin@dal.ca

Useful links

https://crnbc.ca/Standards/PracticeStandards/Pages/boundaries

http://www.socialworker.com/jswve