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Crossing
the Line |
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By
Megan Flaherty Rehab nurse Catherine Grant considers her teen-age patient Matt to be like a little brother. Matt’s hands were severely burned in an accident, and Grant is rooting for his recovery. She goes out of her way to help him, visiting him when she’s off-duty, counseling him about his personal life, and sharing details about her life when he asks. Grant’s supervisors and colleagues have noticed her relationship with Matt, and her nurse manager questions her about it. Grant gets defensive and insists she is hastening Matt’s recovery. Soon after, Matt’s parents file a formal complaint with the state nursing board, claiming the nature of Catherine’s relationship with their son has caused psychological damage and impeded his progress. Matt—who had misinterpreted Catherine’s attention and assumed she was romantically interested in him—is despondent. Grant has unintentionally "crossed the line," hurting a patient and jeopardizing her career.
Fictional situation, Grant—whose predicament is featured on an educational video on professional boundaries and sexual misconduct produced recently by the National Council of State Boards of Nursing (NCSBN)—isn’t a real nurse, but she could be. Nurses frequently become over-involved with their patients, often unwittingly, say experts on professional boundaries and sexual misconduct. "Everybody has some inappropriate situations that come up," said Vickie R. Sheets, JD, RN, director for practice and accountability for the NCSBN. "It’s the professional’s responsibility to set boundaries," she said. When a nurse exploits his or her position of power in the therapeutic relationship to meet his or her needs rather than a patient’s, the nurse has violated those boundaries, she said. Being a friend rather than a professional, using client information, and disclosing too much personal information are common examples. But context can make all the difference, and the same standards don’t apply to all nurses, Sheets said. For instance, a nurse in a small community may be friends with a patient because he or she lives down the block. Or an oncology nurse who has survived cancer may use his or her own story to give a patient hope—a boundary crossing that could be appropriate. "But if I’m taking care of a patient and I say ‘I’m so sick’ and talk about it, the patient would worry about me," Sheets said. High risk situations
Nurses who have repeated contact with their clients, like oncology and kidney dialysis nurses, are at higher risk of over-involvement than those in the operating room or emergency department, where the contact is more limited, said Jean Stevens, MBA, RN, chair of the task force on professional boundaries and sexual misconduct for the NCSBN and director of kidney services at Sacred Heart Medical Center in Spokane, Wash. Home health nurses, who don’t have the safeguard of other people around, also must diligently avoid over-involvement, she said. Nurses who cross the line often aren’t aware of their feelings or don’t fulfill their social needs outside of work, Stevens said. Catherine Grant, the nurse in the educational video, told the patient that her husband traveled a lot, and that she had no one to talk to. The fictional Grant had her license revoked for a year. If a nurse finds herself growing too attached to a patient, he or she should talk to a trusted colleague or supervisor, Sheets said. "If you’re feeling funny about a situation there’s probably a reason," she said. Not just nurses Nurses haven’t been included in most studies analyzing the rate of sexual misconduct among health professionals, although in the last five years nursing leaders have become more interested in the topic, said Gary Schoener, a licensed clinical psychologist from Minneapolis who is an expert in the field. Current studies reveal about 10 percent of psychiatrists, psychologists, and physicians and 1 or 2 percent of social workers admit to having had sex at least once with a current or former patient, he said. The last wide-ranging study of nurses’ sexual misconduct dates to 1974, when 3 percent of women and 2 percent of men acknowledged having sexual contact with patients. Because the study was conducted before the distinction between "current" and "former" patient became a big issue, most nurses probably responded based on whether they’d had sexual contact with a current patient, he said. A continuum of misconduct Less than 1 percent of discipline cases that reach the California Board of Registered Nursing pertain to nurse over-involvement or sexual misconduct, said Susan Brank, assistant executive officer of the BRN. The BRN encourages healthcare employers to report those types of misconduct rather than just firing the nurse so "another hospital doesn’t inherit the nurse without remedy or intervention," Brank said. "It’s our experience that facilities do a pretty good job of reporting serious violations to us." Many supervisors consider it part of their role to report competency or safety issues with nurses," she said. More subtle cases of over-involvement are usually handled within the facilities themselves, said Susan Harris, MPA, RN, senior vice president at the California Healthcare Association. "Most of the time hospitals will try to counsel from within and give employees their rights," she said "All hospitals have procedures on how to deal with egregious behavior," Harris said. In serious cases of overt violence or sexual activity, "hospitals do not look the other way." |
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Setting LIMITS Have you ever crossed the line? The following questions can help you determine whether you’re risking over-involvement with a patient. Keep in mind that what’s unacceptable in one context may be acceptable in another, experts say. *Do you share personal problems or aspects of your intimate life with patients? * Have you ever traded assignments to care for a specific patient? * Have you ever spent off-duty time with a patient? * Do you keep secrets with patients? * Do you become defensive when someone questions your interaction with a patient? * Have you ever given gifts to or received them from a patient? * Have you felt possessive of a patient, thinking that only you could provide the care the patient needs? * Have you ever flirted with a patient? * Have you chosen sides with a patient against his or her family and other staff? SOURCE: "Crossing the Line: When Professional Boundaries are Violated," National Council of State Boards of Nursing Inc., 1998. |
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FIND out more
"Crossing the Lines: When Professional Boundaries are Violated" call the National Council of State Boards of Nursing, (312) 787-6555. |
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