Ethics
Ensuring proper professional behavior
The nurse-client relationship is novel. No formula exists for judging the crossing of boundaries as good / bad, in the absence of considering the features of therapeutic relationship for every scenario. The suitable behavior must be measured with respect to professional’s intent, respecting confidentiality, patient-client advocacy and corroborating the CAN Code of Ethics for Registered Nurses (Corey anad Callanan, 2007).
Violations of professional boundary
The crossings of boundaries are deemed as insignificant, but with the increase in frequency of such incidents of professional boundary violations, it could be serious. The nurse works on the patient-nurse relationship and fulfils the therapeutic needs of a patient and neglects his own. The professional boundary violation is not acceptable as it can spark other occurrences. The professional boundaries occur when conflict arises between client’s needs and professional’s needs. Rationalization can be used to justify this behavior. The violation of boundary is characterized by:
Secrecy
Reversal of roles
Creating double bind for a client
Preferring personal privilege by the professional (Corey anad Callanan, 2007)
The double bind is created for the patient in case their situation is conceded by ending or continuing the relationship with the professional. The nurse violates the professional behavior when nurse uses the relationship to gain for meeting personal goals, and neglecting the client. The professional boundary violations can be termed as abuse. Under the section 2, the abuse of patient constitutes as professional misconduct. It is also a violation of the registered nurse’s code of ethics (Corey anad Callanan, 2007).
Instances of boundary violations
The misuse of power is called abuse. It’s also called perfidy of respect, trust and intimacy between a client and a nurse. It can cause emotional distress to the client. The distress can be physical or emotional. The abuse of clients is not acceptable, either if it’s inadvertent or deliberate. The physical abuse can be exhibited by touching the clients which the client perceives as inflicting physical harm. The unacceptable behavior can range from, hitting, pushing, scratching, kicking, and use of brute force, slapping, pinching, biting, shaking and manhandling the client. The College thinks that least restraint policies must be applicable in all forms of client care settings. Using a restraint is a last resort when all other alternatives are exhausted. The overuse of restraints can be harmful and thus not acceptable (Egan, 2007). This includes:
Skin breakdown
Immobilization
Urinary incontinence
More agitation
Mental deterioration
Physical deterioration
Death (Egan, 2007)
The usage of restraints is understandable as all other ways of not harming the patient didn’t work. The nurse has to resort to least restrictive steps for keeping the patient safe and others around. For instance, a change in the environment can work out, like locking doors to areas off limits can keep the patient and others around safe. Apart from that, total freedom is allowed. The allocation of decisions may have significant effects on the welfare and safety of the patients and clients alike procuring the health care. Sometimes, the registered nurses think that staff facilities and resources issues contribute to poorer care which entails improper use of restraints. Thus, documenting and communicating genuine concerns, offering competent care in the available means and applying necessary improvements are the responsibilities of a nurse (Egan, 2007).
Points to think about
Are the policies on restraint clearly communicated and followed to the letter in health facilities you visit? Does lack of staff, lack of adequate knowledge and lack of resources constitute to unsafe care? What is to be done in case of improper use of restraints? (Egan, 2007)
Verbal abuse is a form communication, which is offensive in nature. It consists of remarks and behavior toward a client that is perceived by the nurse, client and others as demeaning (sexually or racially), sexually exploitative, derogatory, insulting and humiliating. The emotional abuse consists of verbal and nonverbal remarks which show disrespect for a client which are considerably thought of as harmful emotionally by the nurse and client. This behavior can include sarcasm, teasing, bullying, taunting, manipulation, abusive gestures and postures, retaliation, racial remarks, religious bullying, economic remarks, remarks about client’s preferences to sex, remarks pertaining to family dynamics, education and withholding personal information, which could benefit the client’s medical condition (Egan, 2007).
Moreover, the terms such as ‘sweetheart’ and ‘dear’ that can be extremely offensive, disrespectful and demeaning. Also, addressing people in a casual manner can be a huge mistake and shouldn’t be encouraged (Egan, 2007).
Are the policies on emotional and verbal abuse followed and applied in health facilities? What is the course of action to be taken when verbal and emotional abuse is seen?
The sexual abuse means touching the clients in such a manner which seems very intimate and sexually arousing. The clients and nurses find it very offensive. It can also mean starting, engaging and encouraging the sexual intercourse and other types of sexually offensive behavior with the clients (Egan, 2007).
Sexual relationships can bring big differences in the case of clients and patients. The financial abuse can take place in case of taking action without the approval of the client; it can end up in a monetary, personal and material benefit of the nurse. It shouldn’t end up in a financial loss for the concerned client for that matter. Such behaviors can include borrowing money from the client or property from the client, misuse of property and money by the professional, keeping finances by treacherous means and theft, selling of house and property, abusing trusteeship, stealing from bank accounts, taking power of attorney, pressure, influence, using coercion for extracting money from the client and taking guardianship (Zur, 2010; Brammer and McDonald, 2003).
The registered nurses must abide by some guidelines which should protect clients from financial abuse. Are there more guidelines needed? Any more issues needed to be addressed? (Zur, 2010)
Neglect takes in showing off behavior which is deemed by the clients, and nurses alike to breach the professional health care manual. Neglect takes place when nurses don’t meet the requirements of the client who can’t meet their needs. Such behavior can include withholding health care information important for the client, holding back necessities, care facilities such as food, clothing, fluid, equipment as well as medication. Neglect can also occur in the form of holding back information, isolating, confining and ignoring the client, neglecting the client and keeping him away from privileges. In the scenario shown below, neglect can emerge in a nurse-client relationship. The professionals need to help deal with patients and define the boundary signs indicating it’s time for help (Zur, 2010).
Neglect: Price for avoidance
Diane A is a young nurse working in the Long-Term Care Unit. It’s a place where high quality resident care is imparted by the staff and management. The values practiced were difficult to maintain by Diane A while working along Mr. Y who is a 60 years old resident with medical afflictions for instance chronic lung disease, stroke and brain damage. Determining mental competence was a bit difficult and Mr. Y needed full time assistance for his needs which included medications. Mr. Y has swallowing capability. The nurses are advised to use soft pills for him which would liquefy in his mouth. The staff found Mr. Y to be very unlikeable due to his groping habit. Giving him personal care was a bit of a disaster. He would touch them in a manner which would send sexual signals. His mental abilities are questionable but his physical condition was getting worse. Diane felt bad about My Y’s ability and wanted to help him out.
My Y needed pain medication which was intolerable by Diane’s conscience. She would send off RN to medicate him properly and thus avoiding him completely.
Issues: Is being difficult and unlikeable a hindrance in getting the clients their health care. What is the solution to this? Does Diane provide other solutions? Does Diana’s superintendent know about these incidents? For My Y’s behavior, there are plentiful of explanations. My Y’s actions may seem offensive but a foolproof plan can be made which teaches appropriate touches and avoid faux passes.
The exact causes may not be known completely. His underlying condition can play a pivotal role in this case. His individualized care is also to be taken in consideration.
Violations of boundary: Options and solutions
Professional boundaries and competencies
In case of Nova Scotia, the registered nurses are held responsible and accountable to the general population for practicing safe, competent and ethical nursing practices and procure competencies in their relative areas of concern. They should also act as advocates between client and health care system (Tomm, 1993).
The aim of this section is to offer the nurses and other concerned personnel with dealing in situations where violation has took place. In this case, the emphasis is on nurse-client relationship. The violations of professional boundaries can appear in many forms. Do refer to the CRNNS decision making framework on page seventeen. When a person notices a situation which disrupts professional boundaries, the question may arise as to how to tackle this situation?
The CAN Code of Ethics gives the directions. In case of CRNNS decision making framework, primary concern must be client’s welfare (Tomm, 1993).
The nurses should give preference to welfare of a client. The nurses should create an environment which advocates ethical practices and well-being of the client. The nurse should always give preference to the health of a client first (Tomm, 1993).
Irrespective of the nurse’s apprehensions, the best interests of the client must be safeguarded. Discuss the predicament with a trusted nurse who is proficient in making ethical choices and notifying the supervisor is also important. The supervisor will enable changes which will benefit the client. It’s a viable idea to discuss the concerns with College. The CRNNS provincial office can be contacted and taken in confidence at this number (1- [HIDDEN] ). They are able to deal with such situations. The health care professionals, families and clients can also voice their concerns if professional boundaries are violated. Even if the situation is being handled, the concerns must be addressed in the present settings with a colleague. If that is not an option in any case, then CRNNS Professional Practice & Policy Services are available for consultation in confidentiality. Complaining that the employee / colleague are involved in unethical practices which are violating the professional boundaries. The colleague isn’t maintaining the best standards of interests of a client. What should be done in this case? When the nurses have solid grounds for behavior of their colleagues then review the circumstances and think about it, resolve the partnership with fellow colleagues (Bond, 1997).
The nurses should support other nurses in protecting the client from unethical and unsafe care, incompetent care and develop a work environment where interference of the nurses is deemed respectful .The nurses can interfere when others fail to comply to keep the dignity of the clients (Stone, 2007).
The nurse needs to verify the situation first hand herself and then decide on the line of action to take. During the course of an action, relationships in case of health care teams shouldn’t be interrupted. In case, the situation can be solved with no danger to past, present and future clients, discussions with the clients are quite essential. In case, the nurse is hard to confront, the supervisor should be spoken to soon enough. The supervisor is able to explain the cloudy situation and paint a vivid interpretation of the particular situation. Stick to the facts and explain the concerns, and their connection with patient care (Stone, 2007).
The agency proceedings should be followed for reporting these incidents. If the discussion confirms the relative concerns and the situation does violate the professional boundaries then explain the need of the situation to be sorted out. If needed, offer your own assistance. CRNNS staff can also assist in this case of how to tackle a situation. Take further action, if situation doesn’t resolve soon enough. For example, the client with a complaint unresolved should turn to their agency, college and police to pursue their dilemma. If still, the situation remains unresolved then, head to the College of Registered Nurses of Nova Scotia. All the nurses hold a responsibility of voicing concerns about some individual’s conduct. The College will deal with the person’s confidentially and ensure that a complaint is written in regard to nurse’s conduct. In case the written complaint is necessary, the nurse must be notified about such an incident occurring, pending or proceeding. Irrespective of who is tangled in a defilement of professional boundaries, the registered nurse is responsible to act in interests agreeing with those of the client (Zur, 2010).
The College is well within its means to provide assistance to families, clients and professional groups concerned with boundaries. The College can be contacted. Decision Making Framework will ensure in determining if the behavior is suitable (Zur, 2010).
References
Bond T, 1997, ‘Standards and Ethics for Counselling in Action’, pgs Sage Publications Ltd., London
Brammer LM & MacDonald G, 2003, ‘The Helping Relationship, Process and Skills’, pgs Library of Congress Cataloging-in-Publication Data, United States of America
Corey G & MS & Callanan P, 2007, ‘Issues and Ethics in the Helping Professions’, pgs Thomson Brookes/Cole, a part of The Thomson Corporation, United States of America
Egan G, 2007,’The Skilled Helper’, pgs * Thomson Brookes/Cole, a part of The Thomson Corporation, United States of America
Stone J, 2007, ‘Respecting professional boundaries: What CAM practitioners need to know’, Complimentary Therapies in Clinical Practice, http://www. http://www.sciencedirect.com/science?_ob=ArticleURL, February 2008, Vol14, Iss1pgs 2-7, and viewed on 2 February 2010
Tomm K, 1993, ‘The Ethics of Dual Relationships’, http://www.familytherapy.org/documents/EthicsDual.PDF, pgs 1-7, Google Scholar Search Engine, and viewed on the 3 February 2010
Zur O, 2010, ‘Dual Relationships, Multiple Relationships & Boundaries In Psychotherapy, Counseling & Mental Health’, http://www.zurinstitute.com/dualrelationships.html, pgs *, and viewed on the 6 February 2010
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