Professional boundaries – staying safe in the professional role

1. Professional boundaries – staying safe in the professional role Dr Wendy H McIntosh PhD RGN, Grad. Dip. MH, MN

2. 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.

3. A brief intro..... ...and so to the session

4. 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....

5. Stimulate discussion, curiosity, understanding

7. 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)

8. Reasons for becoming a nurse?

9. What guides your professional boundaries? Personal beliefs Family beliefs Community beliefs Religious beliefs Professional requirements Organisational requirements Designated professional role

10. 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

11. 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

12. 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)

13. 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)

14. 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)

16. The boundary framework • . Safe Therapeutic Relations Under involved Over involved (A nurses guide to professional boundaries, ANMC 2010)

18. Four categories of concern • therapeutic relationships • access to / disclosure of information • gifts / services and financial • relationships • dual relationships • (ANMC, 2010)

19. The boundary framework • . Safe Therapeutic Relations Under involved Over involved CONTEXT (A nurses guide to professional boundaries, ANMC 2010)

20. 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?

21. Warning signs

22. 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

23. 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

24. 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”

25. 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”

26. 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?

27. 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

28. Professional boundaries • In place to safe guard… • the patients • colleagues • and YOU

29. Any questions?

30. 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, 1866- • 1889. • 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

31. 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

32. 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

33. Resources Want to access our new internet training tool on professional boundaries ? go tohttp://training.davaar.com.au/ Contact us: wendy@davaar.com.au Web: www.davaar.com.au Mobile: 0411 385 573