Professional Boundaries And Sexual Misconduct

Page 2Ohio NurseMarch 2015Free IndependentStudiesSAVE THE DATEMarch 11, 2015July 15, 2015October 21, 2015OHIO NURSEThe official publication of the Ohio NursesFoundation, 4000 East Main St., Columbus, OH43213-2983, (614) 237-5414.Web site: www.ohnurses.orgBecoming An Approved Provider – 2015ONA Headquarters, Columbus, OHApril 17, 2015All independent studies publishedin the Ohio Nurse are FREE to ONAmembers for three months andcan also be completed online atwww.CE4Nurses.org/ohionurse.Non-members can also complete thestudies published in this issue online for 12 per study or by mailing in the testsprovided for 15 per study. See page 3for more details.Interested in joining ONA? See page3 for membership information and fivereasons for joining the only professionalorganization in Ohio for registerednurses.10th Annual Nursing ProfessionalDevelopment ConferenceOCLC in Dublin, OhioApril 30, 2015Medical Heritage Tea – Friends of NursingSteering CommitteeNursing in the American Red Cross4:00 pm Tea, 4:30-5:30 Lecture5th Floor, John Prior Medical Sciences Library,OSUSpeaker: Sharon Stanley, PhD, RN, FAANJune 2-3, 2015The Retired Nurses Forum of theOhio Nurses AssociationONA Headquarters, Columbus, OHArticles appearing in the Ohio Nurse are presented forinformational purposes only and are not intendedas legal or medical advice and should not be used inlieu of such advice. For specific legal advice, readersshould contact their legal counsel.ONF Board of DirectorsOfficersKathryn Peppe,TreasurerColumbusDiane Winfrey,TrusteeShaker HeightsDavina Gosnell, ChairTrusteeKentSusan Stocker,TrusteeAshtabulaDaniel Kirkpatrick,TrusteeFairbornJill Frey,TrusteeHamiltonLori Chovanak,President & CEOColumbusElaine Mertz,TrusteeCridersvilleThe Ohio Nurse is published quarterly in March,June, September and December.www.ohnurses.orgJune 16, 2015July 22, 2015Summer SeriesSpeaker: Pam DickersonONA Headquarters, Columbus, OHPublished by:Arthur L. DavisPublishing Agency, Inc.October 8-11, 2015ONA ConventionRN to BSN Online ProgramAbout UAFounded in 1870 as Buchtel College, we have about 27,000students representing 45 U.S. states and 80 foreign countries.They’re a culturally diverse group and they come from a broadeconomic spectrum. We offer more than 300 undergraduate andgraduate programs, including many that are recognized nationallyfor their excellence. No CampusVisits Liberal TransferCreditsMSN Online Program Classes That FitYour Schedule CompetitiveTuitionAddress Changes: Send address changes toLisa Walker, lwalker@ohnurses.org / 614-448-1031.For advertising rates and information, pleasecontact Arthur L. Davis Publishing Agency, Inc., 517Washington Street, PO Box 216, Cedar Falls, Iowa50613, (800) 626-4081, sales@aldpub.com. ONF andthe Arthur L. Davis Publishing Agency, Inc. reservethe right to reject any advertisement. Responsibilityfor errors in advertising is limited to corrections in thenext issue or refund of price of advertisement.Acceptance of advertising does not imply endorsementor approval by the Ohio Nurses Foundation ofproducts advertised, the advertisers, or the claimsmade. Rejection of an advertisement does not implya product offered for advertising is without merit, orthat the manufacturer lacks integrity, or that thisFoundation disapproves of the product or its use. ONFand the Arthur L. Davis Publishing Agency, Inc. shallnot be held liable for any consequences resulting frompurchase or use of an advertiser’s product. Articlesappearing in this publication express the opinions ofthe authors; they do not necessarily reflect views ofthe staff, board, or membership of ONF.BSN-LINC: 1-877-656-1483 or bsn-linc.wisconsin.eduMSN-LINC: 1-888-674-8942 or uwgb.edu/nursing/msnCurrently seeking:Professor/School Director - School of Nursing,College of Health Professions, Job ID 8203Serve as the academic leader of the School of Nursingand work directly with the Dean of the College. Bothadministrative and teaching responsibilities will be requiredalong with oversight of the faculty, staff and schooladministration.Required Qualifications: PhD or similar earned degree inNursing or related field with a Masters in Nursing. Eligiblefor licensure as a registered nurse in the State of Ohio,possess a minimum of 5 years of administrative leadershipexperience in Higher EducationAssistant Professor, Nursing, Job ID 7773Teach in the doctoral programs in the School of Nursing(DNP & PhD).Required Qualifications: Doctorate in Nursing, current RNLicense in Ohio, previous experience in Nursing Educationand Certification as an Adult or Family Nurse Practitioner.To view the full announcements and apply s.dotEOEOHBN

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Page 4Ohio NurseProfessional Boundaries continued from page 1nursing care provided and the length and nature of thatcare to determine whether sexual misconduct occurred.Regardless of when a personal relationship is establishedwith a former patient, the nurse/patient role must not beresumed should future ongoing health care needs arise(NCSBN, 2009. p. 6).A case studyNurse A is an independent home care provider for apediatric patient. During the time that she is providingcare to the patient, the nurse becomes sexually involvedwith the patient’s father. The nurse permits the father totake sexually oriented photographs of her, and she engagesin sexual activity with the father in the basement of thepatient’s home. The nurse also becomes aware of maritalproblems being experienced by the patient’s parents. Thepatient’s mother discovers the photographs and a videotapeof the sexual activity between the nurse and the father.Although the sexual misconduct did not involve thenurse’s patient per se, the Board of Nursing found thather actions violated standards of safe care because theterm “patient” includes not only the recipient of nursingcare but also groups or communities. Although the nurse’sactions did not overtly compromise the direct nursingcare provided to the patient, the impact of her actions onthe family unit (community) was extremely harmful andultimately not in the best interest of the nurse’s pediatricpatient. The nurse’s license was indefinitely suspended(Momentum, 2002). While sexual misconduct representsan extreme violation of the nurse/patient relationship,boundary crossings or violations can be equally devastatingfor both the patient and the nurse. Because boundarycrossings are more subtle, they often go unnoticed andare often misunderstood. Nurses frequently believe theyare helping their patients by becoming more friend thanprofessional nurse. This is never acceptable behavior(National Council of State Boards of Nursing, 2011).What are professional boundaries and why are theyimportant?Simply put, “professional boundaries are the spacesbetween the nurse’s power and the patient’s vulnerability”(National Council of State Boards of Nursing, 2011, p 4).These boundaries are not visible. Nonetheless they definethe types of behaviors that are most likely to enable nursesto effectively meet the health care needs of their patientsand their patients’ families. The concept that there are“limits” to acceptable nursing behaviors within the nurse/patient relationship and the reason for those limits formthe framework for an understanding of the intricacies ofprofessional boundaries.“Anything goes” cannot be the watchword to guidenursing behavior. Certain actions are not acceptable whena nurse is caring for a patient. Limits exist to help assurethat a vulnerable patient is not exploited in any way evenby a well-meaning nurse. “The power . comes from theprofessional position of the nurse and the nurse’s accessto private knowledge about the patient” (National Councilof State Boards of Nursing, 2011, p 4). Nurses’ professionalposition affords them control over life-sustaining therapiesand complex equipment through which they exert subtlebut tremendous influence over their patients’ behaviors.This power, which is an essential element in the nurse/patient relationship, enables the nurse to positivelyinfluence the patient’s health status. However, “if the extentof that power is not limited through the establishmentMarch 2015of appropriate professional boundaries, the patient issubjected to unacceptable risks that could ultimately affectthe patient’s physical and emotional health.”(Momentum,2002)The difficulty in defining and maintaining professionalboundaries has long been recognized within thenursing profession. “Professional nursing is emotionallycomplicated. It requires an ability to be meaningfullyrelated to a patient and family yet separate enough todistinguish one’s own feelings and needs.” (Crampton,2001) The innate care-taking style that is a hallmark of thenursing profession increases nurses’ susceptibility to beingcaught up into intense relationships. Further, boundariesand professionalism may be defined differently by membersof the same staff (Crampton, 2001). Casual conversationfor some may be excessive personal disclosure for others.“Joking and camaraderie may be seen as contributingto a pleasant atmosphere in some circumstances butmay lead to boundary crossings in others, particularly ifthe jovial atmosphere is not counterbalanced by a solidunderstanding of professionalism.” (Momentum, 2002, pg1-2.)Boundary Crossings v. Boundary Violations“Boundary crossings are brief excursions acrossprofessional lines of behavior that may be inadvertent,thoughtless or even purposeful, while attempting tomeet a special therapeutic need of the patient. Boundarycrossings can result in a return to established boundaries,but should be evaluated by the nurse for potential patientconsequences and implications. Repeated boundarycrossings should be avoided.Boundary violations can result when there is confusionbetween the needs of the nurse and those of the patient.Such violations are characterized by excessive personaldisclosure by the nurse, secrecy or even a reversal of roles.Boundary violations can cause distress for the patient,which may not be recognized or felt by the patient untilharmful consequences occur.” (National Council of StateBoards of Nursing, 2011, p 4).Case studyA nurse is providing care to an elderly nursing homeresident. The resident¹s family lives out-of-state and isnot able to celebrate holidays or special occasions withher. The nurse begins to invite the resident home for theholidays, and the resident soon begins to count on theseoutings and looks forward to them. The nurse unexpectedlydecides to leave employment at the long-term care facilityand the social interactions with the resident suddenlycease. The resident does not understand what happenedto her “friend” and feels a sense of personal rejectionand desertion. What began as a well-meaning attempt toprovide a positive experience for the resident ultimately hadnegative consequences for her.Avoiding boundary violations does not mean nurses mustsacrifice their helpful natures. Instead, helpfulness mustbe consciously centered along a continuum of professionalbehavior. The “zone of patient-centered care” is located inthe center of the continuum and is the zone in which themajority of patient interactions should take place. On eitherside of the center of the continuum is under-involvementor over-involvement (National Council of State Boards ofNursing, 2011, p 5). When a nurse is under-involved withpatients, distancing, disinterest, and neglect occur.Conversely, when there is over-involvement, the riskof boundary crossings, boundary violations, and possiblysexual misconduct increases. There are no definite linesseparating the zone of patient-centered care from theends of the continuum, instead it is a gradual transitionor melding (National Council of State Boards of Nursing,2011, p 5). Nurses must be wary, however, when theirinteractions with patients border on the edges of the zoneof patient-centered care. Often it is not the action itself butthe motive behind the action that determines whether aboundary has been violated. The complexity of maintainingprofessional boundaries is demonstrated in the followingcase study.Case study“A nurse gives a young female patient a compact discfeaturing a favorite pop singer. The music is intendedto provide a welcome distraction during strenuousrehabilitation exercises. Conversely, a nurse gives the samepatient the same gift, but does it secretly, indicating thatthe gift reflects how special the patient is to the nurse. Onenurse has a therapeutic motive for the gift while the other istrying to be friends.” (Momentum, 2002, pg 2.)The second nurse in the above scenario crossed aprofessional boundary with the patient while the firstnurse did not. The difference is the motivation behind thegift and the way in which the gift was presented. “Whenproviding special privileges to a patient, one must alwaysconsider the motive behind the action. Was it done openlyas encouragement or as a reward for efforts to complywith a care regimen; or was it done to gain approval andacceptance from the patient?” (Momentum, 2002, pg 2.)What does the law say about maintaining professionalboundaries?Ohio law authorizes the Board of Nursing to takedisciplinary action when a nurse fails to establish andmaintain professional boundaries with a patient. (Section4723.28 (B)(31) ORC). Nurses also risk disciplinary action ifthey obtain or attempt to obtain money or anything of valueby intentional misrepresentation or material deceptionin the course of practice. (Section 4723.28 (B)(13) ORC).Rules of the Board further define expectations with respectto boundary violations.* Nurses are not to misappropriate a patient’s propertyor engage in behavior to seek or obtain personal gainat the patient’s expense.* Nurses are not to engage in behavior that constitutesinappropriate involvement in a patient’s personalrelationships.* Nurses are not to engage in any behavior thatcould reasonably be interpreted as inappropriateinvolvement.(Rule 4723-4-06 OAC)Case studiesA nurse has been caring for an elderly patient for severalmonths. Recently the patient has given the nurse gifts thatappear to be family heirlooms. Is this a violation of the OhioNurse Practice Act?Many times grateful patients want to give gifts to theirnurses. The law prohibits obtaining or attempting toobtain anything of value by intentional misrepresentationor material deception in the course of practice. Most giftsare not obtained by deception, so in deciding whether toaccept a gift, one must first determine whether the agencypolicy permits gifts to be accepted. If so, the nurse mustanalyze the motives behind the gift. Often the decisionabout whether to accept a gift becomes an ethical ratherthan a legal dilemma. Gifts that are highly personal, overlysentimental, or represent a large investment of the patient’stime, energy, or money should be graciously and sensitivelydeclined. Gifts from psychotic, delusional, or deliriouspatients must be declined (Momentum, 2002, pg 6).A nurse had b

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