Professional boundaries define effective and appropriate interaction between professionals and the public they serve. Boundaries exist to protect both the professional and the client.
Any behavior or interaction which damages the patient, the professional, and/or the therapy is a violation. It is the victimization and exploitation of a patient by the professional. It is a betrayal of the sacred covenant of trust. This includes sexual and non-sexual misconduct.
Boundary violations harm the patient and the professional. The ramifications are widespread. Damage usually extends to marriages, families, other patients, communities, clinics, institutions, and the profession in general.
The legal environment demands and the public expects strict adherence to professional boundaries. No conscientious professional sets out to violate standards of appropriate, professional relationships with clients or patients, yet violations continue to occur. It can happen to those that are dedicated, moral and highly professional in the overall conduct of their practice. Smart Boundaries™ training is essential for professional protection.
Anyone in a fiduciary relationship is at risk, especially those in the professions of medicine, psychotherapy, law, education and ministries.
Implementation of Smart Boundaries™ fosters healthy and safe boundaries. This improves interpersonal skills, which in turn, reduces the risks for boundary transgressions. Patients, clients, professionals, clinics, hospitals, institutions and corporations are safeguarded.
You can read stories of professional boundary violations and recovery, advice for maintaining healthy boundaries and more in our newsletter, The Practical Professional in Healthcare.
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Individuals with knowledge of a specialized area or skill that requires advanced training and serves others in a fiduciary capacity are known as professionals. Most areas of specialization typically have a Code of Ethics. Professionals are held to a higher standard of conduct by the society they serve. Demonstration of that standard of conduct is called professionalism.
Ethics is a field of study that helps us answer “should” questions, such as “What should I do in this situation?” or “How should I behave?” The field of ethics provides several different methods of answering questions where there are multiple stakeholders and factors to consider. Those methods include consideration of virtues, ideals, and aspirations, and reasoning that considers consequences, moral principles, context, and norms. Professionalism is related to ethics in that one who demonstrates professionalism conducts him/herself according to the ethical principles, expectations, and norms of his/her profession.
Sexual impropriety may comprise behavior, gestures, or expressions that are seductive, sexually suggestive, disrespectful of patient privacy, or sexually demeaning to a patient.
Sexual violation may include physical sexual contact between a physician and patient, whether or not initiated by the patient, and engaging in any conduct with a patient that is sexual or may be reasonably interpreted as sexual.
Well-conceived codes of ethics generally stand the test of time, although novel situations could not necessarily be anticipated when codes were originally developed. Generally, professions update their codes of ethics as needed to assist their members to handle situations that arise over time, such as with the modernization of health care (e.g., use of electronic communication, electronic medical records, etc.).
Generally, no, because the fiduciary relationship between professionals and those they serve remains of paramount importance. However, certain social, cultural, and political forces in the US and other countries have both shaped and been shaped by the expectations of professional behavior among the public. Examples include the ethical principle of respect for patient autonomy that underlies the informed consent process, the widespread accessibility of institutional ethics committees, and laws and documents that set forth patients’ rights. Whereas certain boundary crossings, such as inappropriate language in the operating room or unchaperoned exams, had been tolerated in the past, that is much less true nowadays.
Ethics remediation is a process intended as a remedy or corrective intervention for a lapse in ethical behavior. It assumes that the person who erred is of inherent value to his/her profession and has the characterologic potential to learn from past mistakes, hold him/herself accountable, and adhere to future safeguards. Ethics remediation can be accomplished through a formal program or curriculum that provides opportunities for reflection and analysis of the professional’s particular situation. It is most successful when delivered in a classroom or one-on-one setting. In fact, coupled with the development of a plan to safeguard future behavior, it is the only intervention that has demonstrated success in helping professionals avoid recidivism.
Sexual harassment is a type of boundary violation that usually refers to behavior in the workplace between employers and employees, co-workers, or supervisors and personnel. Sexual harassment can be physical or verbal. In certain workplaces and professions, sexual harassment has a range of specific meanings. Every professional should consult with his/her workplace’s and profession’s definitions to become educated about the kinds of behavior that others might find offensive, threatening, or detrimental to a collegial working environment.
It is a bit less common nowadays for healthcare professionals to be reported for paternalistic behaviors, largely because of widespread education in and acceptance of the informed consent process and ways of effectively and sensitively delivering bad news. However, lapses in clear and respectful communication still occasion patient and employer complaints to regulatory agencies. In addition, the use of electronic health records and social media platforms have brought about many novel ethical dilemmas that healthcare professionals may not be equipped to handle appropriately.
These terms are used as general labels for objectionable and actionable conduct, arising from state statutes that delineate the expectations of ethical conduct for licensed professionals. Admittedly, these are general terms that can apply to a wide range of infractions. The process of remediation can assist the accused to understand with greater specificity and nuance the lapse in professionalism they need to work on, including how they went off track and how they can get back on track and stay there.
Many professionals are in a position to supervise trainees, other professionals, and office staff. Some supervisory relationships, such as that between a physician assistant and a physician, have clear and formal requirements and expectations that must be followed. Other supervisory relationships, such as a student rotating through a faculty member’s clinic, are less formal. The primary ethical issue is one of accountability. As “captain of the ship,” the licensed professional is ultimately responsible for all the activity in his/her domain, and has a duty to ensure the integrity of those activities.
Once you write a prescription for anyone, that person becomes your patient. However, sometimes emergencies or extenuating circumstances arise. A general rule of thumb is that, in the case of an emergency or a one-time need (e.g., a refill of your spouse’s anti-hypertensive medication before the pharmacy closes), it is permissible. But such prescribing or refilling with any regularity is inappropriate, as this constitutes medical care and creates a dual relationship. Each patient (including you!) deserves appropriate evaluation and treatment by their own healthcare professional. All states prohibit prescribing controlled substances to oneself or one’s family members except in an emergency.
Sometimes bartering occurs in rural areas where patients may be uninsured or lack the ability to pay otherwise. In such cases, the usual sensitivities to relationships in the community and vigilance regarding the potential to develop exploitative or dual relationships should guide the healthcare professional’s decision to barter. Outside such rural settings, however, bartering has the potential to adversely affect the fiduciary relationship between healthcare provider and patient through misunderstandings, feelings of coercion or exploitation, or concerns about self-serving motives. Finally, if one barters on more than just an occasional basis, there may be “income” reporting requirements for the purposes of taxation.
Different professions have different norms regarding this practice. Your professional society is a good place to seek advice and learn the professional consensus for your particular type of practice. However, there are some specialties where treating co-workers or employees is prohibited or highly discouraged—such as psychiatry, obstetrics and gynecology, psychology, or counseling—because the intimate nature of those specialties would complicate the existing collegial or supervisory relationship by further shifting the balance of power.
Sexual harassment is a term used for unwanted overtures by one party towards another. A dating relationship is presumed to be mutually desired and consensual. However, if there is a supervisory relationship between the individuals who choose to date, they would be well advised to eliminate that supervisory component. If the supervisory arrangement cannot be changed, then the dating relationship would be inappropriate.
The chief concern about dating a current or former patient has to do with the power gradient in the relationship. The sharing of intimacies can create ambiguities regarding exploitation and self-serving motives. Different professions and different states have their own regulations regarding decisions to date a current or former patient. Your professional society is a good place to learn what the standards are in your profession and in your state. As one example, however, the American Medical Association’s position is that sexual contact with a current patient constitutes sexual misconduct. Further, the field of psychiatry holds to the “once a patient, always a patient” dictum, meaning that it is never ethically permissible to date a current or former patient.