Professional Ethics in the Workplace

The blurry boundary between ethical and unethical behaviors can lead professionals with the best intentions to cross to the lines without realizing they have erred. “Out of Bounds: Crossing the Lines of Professional Boundaries,” a panel discussion conducted Monday by Scott R. Ziehm, assistant dean and clinical professor of psychiatric nursing at the University of California San Francisco (UCSF), Judith Laughlin, pediatric critical care social worker at the UCSF Children’s Hospital, and Hildy Schell, adult critical care, clinical nurse specialist at the UCSF Medical Center, addressed the ethical issues that arise when close relationships form between professionals, and patients and their families. For the purposes of raising awareness and beginning an open dialogue among clinicians, the speakers directed attendees to consider one of the definitions of boundary crossing as prescribed by the National Council of State Nursing Boards which states: “Boundary crossings are brief excursions… that may be inadvertent, thoughtless or even purposeful if done to meet a special therapeutic need.”

Consequences of Crossing the Line

The consequences of crossing professional boundaries affect more lives than just that of the clinician. Patients and their families are also a part of the fallout as is the critical care team.

This effect was further explored when the speakers discussed case studies involving confusion among family members concerning planned patient care and a loss of trust due to different opinions among the critical care team.

When healthcare providers cross medical practice boundaries, they also risk professional consequences, including charges of professional misconduct, loss of credibility, legal action and problems among colleagues. In addition, medical teams suffer from a decrease in trust resulting in a loss of effectiveness when an open dialogue is not employed.

Defining Boundaries

To ensure adherence to professional boundaries, they must be well-established. Unfortunately this is easier said than done given the varying factors and sensitivities that need to be considered on a case- by-case basis. To determine if a provider’s actions might be regarded as crossing boundaries, the speakers encouraged attendees to consider some questions. For instance; would I do this for all of my patients? What is my motivation in taking this action? Is this action something that my colleagues would perform? Are my actions fostering autonomy? Am I willing to talk with my colleagues about these actions? These questions can be applied to a number of different situations such as gift giving and receiving, giving your home phone number to families you feel close to, and visiting certain patients on your day off. If healthcare providers find they are acting in their own interests or against suggestions of the team, they might want to reconsider their behavior. Ultimately you want to act in the best interests of the patient, Schell said, which is the final deciding factor in critical decision-making and can sometimes lead the healthcare provider to a gray area in terms of boundaries.

Surprising Insight

Over-involvement is the most commonly discussed form of boundary-crossing. Providers feel best when working with patients, Ziehm said, but this becomes problematic when that provider begins to undermine the suggestions of other members of the medical team or spends more time with that patient than necessary.

Being under-involved by avoiding a patient’s family members or asking a colleague to treat a patient who you dislike can also be damaging.

Zeihm reminded the attendees that boundaries are not intended to stifle relationships and present a cold-hearted demeanor, but to add a level of consistency that will benefit all parties.

“Boundaries provide security for people in crisis,” Ziehm said.