Three Approaches to Boundary Crossings
A middle-aged man she’s known for years sits sobbing in Dr. Elbert’s examination room. His wife has recently left him and Dr. Elbert has just told him that he has an aggressive cancer and may not live long enough to see his first grandchild born. To show no compassion for her patient would seem cruel and likely to undermine the patient’s trust in his doctor just when he needs it most. But even a friendly show of concern—a gentle hand on his shoulder and a few softly spoken words—might be misinterpreted by a man in such a vulnerable position, especially one who’s made playfully flirtatious comments in the past. What should Dr. Elbert do?
Even if there’s a chaperone in the room, it’s an agonizing choice. And if the doctor is someone who only recently had her license threatened by an accusation of sexual misconduct, she is likely to err on the side of caution. Then again, if she has been through similar situations numerous times over a long, untroubled career, Dr. Elbert is more than likely to reach out, both literally and figuratively. Either choice comes with risks.
The Slippery Slope
A simple show of concern is more likely to be labeled a “boundary crossing” than a “boundary violation,” although everything depends on the patient’s interpretation. There is no clear bright line separating crossings, which are usually defined as momentary and harmless, from violations, which cause a patient real harm.
In its most extreme form,, the “slippery slope” model argues against crossings of any kind. The Missouri Physicians Health Program (MPHP) says on its website that while boundary crossings “may be initiated with the best of intentions,“ they can lead a practitioner to “progressively tumble down a “slippery slope” of professional destruction.” For someone fearful of repercussions, the safest course, according to this model, is to avoid all boundary crossings.
Many would argue that this is impossible. In actual practice, occasional crossings are inevitable, and often go unnoticed by either the practitioner or the patient. The real danger comes when there is a history of crossings. It’s easy enough to step back after a momentary transgression, but if you repeatedly step out of line, you may well find it increasingly difficult to stay out of trouble. And if the repeated crossings grow more egregious over time, you are almost certainly heading for a tumble down the slippery slope.
The key to safety in this model is to recognize when you have crossed a boundary. It’s important for all practitioners who treat patients to know where the boundaries are, and to have colleagues who are willing and able to tell them when they see a crossing that the practitioners themselves may have missed.
The Continuum of Professional Care
While the slippery slope model protects the practitioner against risk, some argue that it can also prevent a patient from receiving the best possible care. Most professional groups, for instance, would agree with MPHP that, “the injudicious sharing of private information is clearly a boundary crossing and interferes with the aim of the professional relationship.” But is it injudicious for a nurse practitioner to share his own successful struggle to give up smoking with a patient who is in the midst of such a struggle? Might this not be an example of a crossing that is, in the words of A Nurse’s Guide to Professional Boundaries, “attempting to meet a special therapeutic need of the patient?”
Instead of a slippery slope, the National Council of State Boards of Nursing (NCSBN) advises its members to conceive of every relationship with a patient as “continuum of professional behavior” and provides the following graphic.
Where advocates of the slippery slope warn of going too far, the NCSBN warns against both going too far and not going far enough. “Over involvement includes boundary crossings, boundary violations and professional sexual misconduct. Under involvement includes distancing, disinterest and neglect, and can be detrimental to the patient and the nurse.”
The NCSBN’s Guide to Professional Boundaries presents the continuum as “a frame of reference to assist nurses in evaluating their own and their colleagues’ professional-patient interactions.” Instead of advising against any boundary crossings whatsoever, the NCSBN encourages its members to make sure they know when they are crossing a boundary and to think through whether or not they are doing so for the good of the patient.
While the Guide to Professional Boundaries provides a variety of guidelines to help nurses make these decisions, including “red flag behaviors”, three questions are singled out as essential:
- Was the crossing in the patient’s best interest? (Was it for a therapeutic purpose? Did it optimize or detract from the nursing care?)
- Did the nurse consult with a supervisor or colleague?
- Was the incident appropriately documented?
If a practitioner can answer, “yes” to all three questions, he is very likely to remain within the bounds of a therapeutic relationship (or what the Journal of Nurse Practitioners calls “the zone of helpfulness”), and to have adequately protected himself against any future accusations.
The Graded-Risk Model goes further than the continuum approach. In his article, A Model for Boundary Dilemmas: Ethical Decision-Making in the Patient-Professional Relationship, Richard Martinez notes that there are times when crossing a boundary is not only worthwhile but, in fact, ethically and professionally required. “An obligation is a situation where the failure to extend oneself (i.e., to cross a boundary) may constitute substandard care, even a potential for malpractice liability,” he writes. Such cases range from the commonplace (offering to extend office hours) to the heroic (“professional behavior that is beyond the call of duty”).
Martinez provides a structured approach designed to help practitioners think through risks and benefits in order to classify potential crossings into one of four categories (see chart). Crossings that fit into the first two categories, in which the risk of harm to the patient is high, are discouraged or prohibited. But in categories III and IV, crossings are encouraged to varying degrees.
To determine which category applies, practitioners are asked to consider six specific ethical issues:
- The potential harm to the patient and the relationship
- The potential benefit to the patient and the relationship
- The presence, absence, or degree of coercive and exploitative elements in the boundary crossing
- The professional’s motives and intentions
- The professional’s aspiration to professional ideals
- The context of the boundary crossing (such as an assessment of the patient’s psychological strengths and weaknesses and cultural variables including race, ethnicity and gender).
Martinez argues that, “Rule-based decision making, unfortunately, leaves many professionals focused on what is the minimum of effort rather than exploring innovative ways of helping patients,” and that the graded-risk model “supports broader obligations to patients.”
Some might claim that the continuum model is as effective in this regard and is far simpler to use in the often-fleeting moments when decisions have to be made. Whatever the relative merits of the two approaches, Martinez notes the added value of his model in reassessing decisions after the fact. The goal, he stresses, is not “to determine culpability,” but to use the structured model to analyze past incidents and learn from the analysis how best to behave in the future.
No matter which approach one adopts, the advice from the NCSBN can help protect a practitioner’s interests at the same time as the patient’s:
- When in doubt, consult with a supervisor or colleague
- Always acknowledge a crossing and document how the decision was made.