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Boundaries

 

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A major concern for many staff is getting the balance right between being warm, friendly, human, normal with patients – and crossing boundaries. What if the relationship gets too close? This can mean firstly the patients gets too close to you or you get too close to the patient. The problem here is what does ‘too close’ mean.

The nurse/professional carer role involves being physically and emotionally intimate with patients. This is an essential part of care and must be based on trust and respect – we know this. But we’re saying that we need to have relationships with patients, however brief, and these maybe difficult. We need to know where we are.

Here are some real life examples of going outside the acceptable boundaries of the relationship (a nurse was suspended for a year because of these):

  • Giving a patient personal information about herself and her family including her home telephone number and a photograph of a relative
  • Giving the patient her partner’s and relatives names then discussing her private life and relationships
  • Going on holiday with her family and a patient
  • Accepting several payments from a patient.

Of course this doesn’t stop you having a laugh with a patient ‘My partner never puts the cap on the toothpaste’ hahaha ‘neither does mine’ etc etc

The other issue is the sexual one. The NMC has a zero-tolerance approach to sexual activity with patients, so will your hospital Trust. Disney says safety first and that means safety of staff as well. It’s usually clear when a patient approaches you sexually either verbally or physically. Do get advice and help from appropriate senior staff if this happens to you.

BUT what about when a health professional gets ‘too close’ – what is too close?

You need the self-awareness to recognize behaviour which may show you’re attracted to a patient and moving towards breaching professional boundaries, such as:

  • Giving or accepting social invitations especially if it’s sexually motivated
  • Visiting a patient’s home unannounced and without an appointment
  • Seeing a person in your care outside normal practice
  • Clinically unnecessary communication – includes texting and Facebook!!

So what are breaches of sexual boundaries? Examples include:

  • Beginning a personal relationship during or after treatment
  • Engaging in sexual activity
  • Discussing sexual matters that are not relevant to treatment
  • Using sexual humour or telling ‘dirty jokes’
  • Repeatedly engaging in conversation about personal sexual matters unrelated to treatment.

In short disclosing personal information (this doesn’t include your name, but beware of Facebook); accepting gifts (this doesn’t include the box of chocolates given to the ward); going on holiday with patients and engaging in sexual activity with patients are ‘too close’.

Source: Professional boundaries in the nurse-patient relationship, by Griffin R, 2013, British Journal of Nursing

 

 

Responding to personal or sexualised questions and comments

Being asked personal questions, or other questions that you don’t feel comfortable answering, is yet another occasion when mind- awareness is very handy! It can be very difficult in this situation to think beyond: ‘Blimey! That’s much too personal! Can’t possibly answer that.’ And this could be accompanied by feeling anxious or even angry. But if you can stretch your mentalising to include considering what the patient may be thinking and feeling, this should help. For example, the patient themselves may be very anxious,

and realise that it’s an inappropriately personal question but feel so desperate to know about someone else’s experience that they’ll risk asking. (Or, sometimes patients are just chancing their arm or being nosey!)

The most important thing about responding to this sort of question, is, perhaps, not the words staff use, but the tone of their voice and the expression on their face. If they smile and say something gently, or humorously, most patients will understand and accept that the member of staff can’t answer the question.

It’s sometimes possible to politely ignore the question and carry on the conversation. But better to say this sort of thing:

  • I can see why you’re asking this, but we’re here to talk about you not me. (The classic therapists’ answer.)
  • I’m afraid I can’t really talk about that
  • Thanks for being interested, but I don’t think that knowing about my experience will be any help to you.
  • I’m sorry, but that’s a bit too personal for me to talk about.
  • Is there a particular reason why you’ve asked that?

An invaluable ploy in situations where staff are asked a difficult question is to buy some time. A patient will appreciate that staff are taking their question seriously and courteously if something like this is said: ‘Hmm. I’ll need to think about how best to answer that. Can I get back to you on that one?’ This will genuinely give you time to think about how to respond, and also to consult a colleague.

 

 

Q. 1 What phrases do you use, or might you use in future to respond to personal or uncomfortable questions?

 

 

Q. 2 How do you think mind-awareness helps when a patient asks you a very personal question?

Examples:

  • Being aware of your own thoughts and feelings, especially if they’re so strong that they get in the way of being properly in tune with the patient
  • Working out what might be going on in the patient’s mind e.g:

What do you know about the patient’s past experiences (e.g. having been abused or bereaved) that might explain more about the purpose of the question?

Is there a more hidden, important, underlying reason why they’re asking that question?

What is their body language saying about how they’re feeling at this moment? Is it aggressive? Withdrawn? Distressed?

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