The Nursing and Midwifery Council have recently commenced running a program of events about their role and responsibilities across NSW.
Interactive workshops and forums have been exploring patient safety and the shared responsibility of nurses, midwives and regulators as well as the importance of developing organisational cultures of safety and maintaining professional standards.
During our most recent event in a rural location, participants highlighted managing professional boundaries as a key standard for focus.
So, what exactly are professional boundaries?
In nursing and midwifery, professional boundaries may be defined as 'limits which protect the space between the professional's power and the client's vulnerability' and allow for safe, objective and effective engagement with a person (Nursing and Midwifery Board of Australia, 2010).
Boundaries are the borders or limitations that a professional establishes (or can assist other professionals or persons in their care to establish) in order to protect them and their clients from developing unprofessional, unethical, confusing or conflicting relationships. Some of these boundaries may be very clear and others more complex and blurred. They also may change over time and in different contexts of healthcare.
If there are concerns about a boundary being crossed between a personal and a professional relationship with a client, it is important to seek guidance. Discuss with a manager or educator about how to best to manage the situation and minimise potential issues.
It is important that all professionals and students understand the standards of behaviour and conduct expected of them. Boundary violations can have serious consequences for the professional in relation to their registration, resulting in findings of unsatisfactory professional conduct or professional misconduct. A professional and therapeutic relationship is required for all contexts of care.
Maintaining the power balance
Clients and communities trust that nurses will be safe, ethical and unbiased, and act in the best interest of those in their care. In order for this to happen, a power balance must be maintained by discussing professional boundaries and limitations with clients. This is of paramount importance in situations that arise where there is the potential for a blurring of the relationship between personal and professional roles.
When setting boundaries, a nurse or midwife is accountable for establishing the professional relationship, which is at all times based on therapeutic plans and goals for the client.
Due diligence must be taken when close and long-term professional relationships occur and either the practitioner or client may blur the boundaries towards a more personal relationship. This blurring can lead to a confusion of roles and responsibilities and poorer therapeutic outcomes. This needs high consideration in contexts such as mental health, paediatrics, community nursing and midwifery.
A framework for legally and professionally accountable and responsible nursing and midwifery practice is provided within the Code of conduct for nurses in Australia (2008), the Code of conduct for midwives in Australia (2008),the Code of ethics for nurses in Australia (2008) and the Code of ethics for midwives in Australia (2008), together with practice standards. NOTE: The new Code of conduct for nurses and Code of conduct for midwives are due to come into effect on 01 March 2018. View the advance fact sheet and copies.
The Nursing and Midwifery Board of Australia also provides some helpful guidelines and tools for use when setting professional boundaries including a decision-making framework and ethics.
Some behaviours that require attention when establishing and reflecting upon boundaries include;
- A non-professional pre-existing relationship exists
- Intimate relationships
- Excessive self-disclosure
- Over involvement in care
- Secretive behaviour
- Preferential treatment or a person paying extra attention to the nurse or midwife
- Selective communication
- Flirtations
- Sexual misconduct/assault
- Poor documentation
- Social media contact
The complexity for nurses and midwives in remote or smaller communities
It can be particularly complex for nurse and midwives working in regional or rural areas or close-knit communities when identifying potential boundary issues.
A professional working and living in these communities will out of necessity have business and social relationships with the people for whom they provide care. The need to manage potential conflict becomes more important, especially when the community has expectations that you are potentially ‘on duty’ at all times. This is not unique to health professionals. There is a difference between having a friendly professional relationship, being an acquaintance and being a friend. Sometimes these relationships can be in conflict.
So what can a professional do to avoid a boundary violation?
Some good steps to avoiding crossing professional boundaries include;
- Be clear in your mind about your professional role and obligations when at work and your role and responsibilities when you socialise
- Be clear with friends, family and acquaintances about when you are on duty and when you are not
- Ensure your behaviour meets the needs and best interest of the clients and is clearly defined within the clients’ care plan
- Ensure your care is objective and does not have the potential to be seen as favouritism or conflicted by an existing or prior relationship with the client
- Regularly reflect on practice - discuss with colleagues in the appropriate forum (and not on social media) stories and scenarios that give examples of situations which highlight potential and real professional relationship and boundary dilemmas for nurses and midwives
- Discuss with a manager or educator any complex relationships or concerns over boundary violations
- Accurately document any treatment and strategies in place to manage the professional and personal nature of a relationship if this is an issue
- Avoid privacy breaches
- Uphold the codes of professional conduct and ethics and ensure behaviour is in line with these as well as within scope of practice and organisational policies
- Ensure competency for scope of practice and understand your accountability as a professional
- Explore possibilities for clinical supervision within your workplace/speciality area of practice
What would you do....?
It is a good idea to regularly reflect upon or discuss different scenarios and management strategies. Below are some situational examples. Take a look at each and discuss with a colleague what you could put in place to ensure professional boundaries are appropriately managed. If you are feeling confused or overwhelmed by a situation you could call the Nurse & Midwife Support Service on 1800 667 877. This free service operates 24/7 and provides access to confidential advice and referral.
1. Your neighbour of five years is in the supermarket buying some groceries. They slip over and can't get up or move their arm. You are well known within the community and as you are a nurse, the store manager makes a call for you over the intercom to come and assist with the situation.
Suggested actions to avoid a boundary violation ...
Make it known that you are rendering first aid care; ask for an ambulance to be called or another health practitioner. As you render first aid, advise what you are doing at all times. Remain within the scope of practice of first aid only. Hand the care over as soon as possible.
2. You treat a man whilst working a shift at Accident and Emergency. He is admitted to hospital for a few days after having had an accident at work, however, you only make an initial assessment when he first arrives to hospital. Six months later you see the man in your local pub. He has made a full recovery and is no longer having treatment. You are getting on really well, exchange numbers and agree to go out for a date. It went well and you have now been dating a few months.
Suggested actions to avoid a boundary violation ...
This is a tricky one that will create many different views. Essentially once you have had a therapeutic/professional relationship with a client then you should not have an intimate sexual relationship with that person, particularly if you are likely to provide ongoing care for that person in the future. Consider the extent of your professional relationship, the nature of the patient professional relationship, the age of the patient, their vulnerability and the ongoing professional interaction. Does a power imbalance exist and what if the relationship deteriorates? Advise your manager that you are dating, if you are keeping the relationship a secret, ask yourself why?
3. You see a rather unusual case and take a photo to send on to a consultant you know in Sydney who may be able to provide some further advice for treatment. You take the photo on your personal phone and send the image to him via email.
Suggested actions to avoid a boundary violation ...
Did you obtain an informed consent from the patient? Is this a medical record? What are the regulations around the storage of medical records? What if the image goes public? What do you do with the clinical advice given to you by the consultant? What if your phone is lost or accessed and the image distributed widely? What of you send it to the wrong email?
If you are required to send photos for clinical advice speak to your employer regarding a safe way to do this and for the consultation to be part of the medical record. Do not take photos for reasons other than seeking professional clinical advice.
4. A good friend of yours is having a baby and has asked you to be their midwife.
Suggested actions to avoid a boundary violation ...
Straight away you should advise them that you are flattered but it would not be in both your best interests. There is a clear conflict here. Can you be objective in determining care? Will they tell you everything you need to know to provide adequate care, for example they might not disclose some information due to embarrassment i.e. domestic issues. Are you the right person in relation to skill and complexity of the case? What if something goes wrong and there is a poor outcome? Will your friendship survive?
It is best to be a support in this case and allow another midwife to objectively provide care. In rural and small communities this is very difficult as is the case of colleagues having babies. It is paramount that all strategies are in place to manage these situations as professionally and objectively as possible.
5. You are at a barbecue with a group of friends and one friend starts discussing a health issue they have. They ask what you think of the condition and whether you can recommend any advice.
Suggested actions to avoid a boundary violation ...
Some people believe you are on duty 24/7 and the advice you give will be taken professionally so…..What if your advice is wrong, not evidence based, challenged by others at the BBQ or you are intoxicated with alcohol and give them incomplete advice? What if they follow your advice and something goes wrong?
Politely advise that as you're not on duty, you won't be answering their inquiry but give them a way to get the advice they need, like who to see and when.
6. You are in the local coffee shop and overhear some people concerned and talking about the health of an acquaintance you play netball with. You are working a shift at the hospital and your acquaintance walks into another department and you're not involved in their care. You decide to look at the acquaintance’s records to check their condition and treatment plan. Later you discuss the matter with your mother on the phone who also knows of the acquaintance.
Suggested actions to avoid a boundary violation ...
This is a clear boundary violation, a breach of the code of conduct, a breach of privacy legislation and a breach of the trust given to the profession. You can only look at records of the people in your care and for the purpose of providing ongoing care. All records accessed can be audited. This access is not in keeping with the code of conduct or relevant policy and would be managed accordingly. A breach of the code of conduct can result in termination of employment or may be considered as unsatisfactory conduct.