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Professional Boundaries inHospice & Palliative Care

Presented byMark Ritchie, LCSW

Director of Patient ExperienceSeasons Hospice & Palliative Care

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• Remain for entire presentationo 1 hour

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o Your NCPD (Nursing Continuing Professional Development)/ CME/ SW CE Category I certificate for 1 credit hour(s) will be emailed to you within 24 hours.

Send questions to communityeducation@seasons.org and our Community Education team will be happy to help.

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Declarations

• This program is provided to you by Seasons Hospice & Palliative Care.

• There is no commercial support for this educational event.

• The speaker declares that they are an employee of Seasons Hospice &

Palliative Care, which provides the service described herein.

• Planners, presenters, faculty, authors and content reviewers declare no

conflict of interest.

• Approval by ANCC/ASWB/CCMC/AAFP does not indicate endorsement

of any products.

• This presentation expires September 8th, 2023.

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Professional Boundaries in Hospice & Palliative Care

Presented byMark Ritchie, LCSW

Director of Patient ExperienceSeasons Hospice & Palliative Care

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Objectives

▪ Define professional boundaries in healthcare settings.

▪ Recognize the importance of professional boundaries.

▪ Identify healthy boundaries and how to maintain them.

▪ State skills that reinforce and re-establish healthy boundaries.

▪ Recognize the professional responsibilities in maintaining healthy

boundaries

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Professional Boundaries Defined

▪ Professional boundaries are established to set limits to the

provider-patient relationship

▪ Are set by legal, ethical and organizational frameworks

▪ Establishes a therapeutic connection between the professional

and the patient

▪ Maintains a safe psychological working environment for both the

client and the caregiving staff

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Professional Boundaries Variables

Who establishes boundaries?

The professional caregiver leads the way, considering the

factors that may affect boundary delineation:

▪ Care setting

▪ Community influences

▪ Patient needs

▪ Nature of therapy

▪ May include physical, emotional and mental involvement

limitations

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Professional Boundaries: Continuum of Behavior

Under-involved

Zone of Helpfulness

Over-involved

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Zone of Helpfulness

▪ Continuum Center, think balanced therapeutic

relationship

▪ Characterized by trust, respect, intimacy & power

▪ Provider maintains healthy boundaries to honor

these and facilitate healing relationship

▪ Example: Self disclosure use is limited to…

▪ Building rapport

▪ Normalizing the situation

▪ Creating comfort between patient/family and provider

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Under-Involvement

▪ Left side of continuum

▪ Includes distancing, disinterest and neglect

▪ Studies show nurses in acute care spend less time with dying patients

▪ By not addressing their own discomfort, they are not fully present for the patient

▪ May be “playing favorites” with some patients, and may

distance or neglect others

▪ Negatively affects therapeutic relationships

▪ Patient / family feel the lack of involvement and caring, and/or anger from the

clinician

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Over-Involvement

▪ Right side of continuum

▪ Includes boundary crossings, boundary violations, and/or sexual

misconduct

▪ Care staff find themselves “shoulding” on patients (“if I were

you…..You should…..”)

▪ Boundaries are crossed and emotional relationships are

“kidnapped”

▪ Clinician falls into role of a family member

▪ Clinician falls into the parental role

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Continuum of Behavior

▪ No definite lines separation the zone of helpfulness

from the ends of the continuum

▪ Is a gradual transition or melding

▪ Lines may be crossed without our immediate

awareness

▪ Slippery slopes

▪ Blurs boundaries

▪ Negatively affects therapeutic relationship

▪ May lead to compassion fatigue

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Boundary Breaches: Where may they lead? ▪ Risks to the patient / family, and your caseload

▪ Unfair treatment from patient to patient

▪ Focus shift from pt/family needs

▪ Creates dependence on one professional, not the team

▪ Risks to you, the caregiver

▪ Can lead to burnout

▪ Moral distress

▪ Compassion fatigue

▪ Risks to your co-workers

▪ Sabotages relationships within the team.

▪ Makes the team more vulnerable to manipulation

▪ Prevents pro-active problem management

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Professional Boundaries: Why?

To protect the patient

▪ Protect against potential exploitation

▪ Protect against inconsistent sub-standard care

▪ Protects patient self-determination and dignity

To protect the clinician

▪ Protect clinical team integrity

▪ Protect against moral distress, compassion fatigue, burnout

To protect the agency

▪ Legal and liability issues

▪ Trust and reputation

▪ Data has shown that for every bad experience a person has with a

business, they tell 12 people…

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Warning Signs of Boundary Blurring

Professional / Family member role blurring:

• Attending family events Attending wakes/funerals

• Sharing personal contact information (call me first)

• The healthcare provider revealing excessive personal information

• Patient/family expectations that the provider will provide care or socialize outside of clinical care settings

• The clinician presenting own religious / spiritual views

• Gift giving to or from patient/family

• Hugging

• Dual relationships

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Boundary Breach Prevention:Responsibility Framework

▪Self-Awareness - insightfulness

▪Self-Monitoring - vigilance

▪Self-Care - mindfulness

Under-involved Zone of Helpfulness Over-involved

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Self-Awareness: Insightfulness

▪ How are you, the professional, feeling?

▪ Over-burdened trying to keep up?

▪ “They won’t use the 24/7 line, they called me 2 times last night”

▪ “I do and do for them, and they just want more”

▪ “I like being needed”

▪ “The daughter won’t even consider Social Work help, that’s one more thing I need to do . . .”

▪ If not addressed can affect you in your caregiving role, and the patient/family care, and your personal life

▪ Inability to act in a manner consistent with personal/professional values due to external constraints → moral distress & compassion fatigue → burn out

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Self-Awareness

▪Questions used to explore use of boundaries in your practice:▪ Whose needs are being met in the relationship?

▪ Would you feel comfortable or uncomfortable about colleagues or your manager observing your behavior?

▪ If challenged, can you ground your actions and interactions in the theories and values of your discipline?

▪ Is your relationship with the pt/family/CG adversely affecting your clinical judgement?

▪ Does the type of relationship you have with a patient or their family change your professional treatment or management?

▪ Do you think you are the only one who understands and can help this family?

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Self-Awareness: Self-Disclosure Considerations

▪ How is the self disclosure enhancing the professional relationship with

the patient?

▪ Whose need is being met through self disclosure – the patient/family’s or

the provider’s?

▪ How does self disclosure impact the relationship and the comfort of the

patient/family to express themselves to the provider?

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Self-Monitoring: Vigilance

▪ Continuum of Behavior framework helps to evaluate the provider’s professional-

patient interactions

▪ For a given situation, the facts should be reviewed to determine if the provider was

aware of a boundary crossing and why:

▪ What was the intent of the boundary crossing?

▪ What form does it take?

▪ Was it for a therapeutic purpose?

▪ Was it in the patient’s best interest?

▪ Did it optimize or detract from the care?

▪ Did the provider consult with a supervisor or colleague?

▪ Was the incident appropriately documented?

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Case Study: We Are Family

▪ Kate is a new hospice social worker, moving from the acute care setting as a discharge

planner. Her patient, John, has been married to Gail for 43 years and together they have 4

adult children and several grandchildren.

▪ Kate developed a close relationship with John and Gail, and they often had home-baked

cookies awaiting her visits.

▪ John experienced a symptom crisis that prompted Kate to give Gail her cell phone number

as a gesture of reassurance and comfort.

▪ As John’s conditioned deteriorated, Gail began calling Kate 2-3 times per week. Kate’s

visits increased and over time, Gail began to invite her to Sunday dinners and the

grandchildren’s birthdays. Kate felt obligated to attend.

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We Are Family

▪ As John’s condition worsened, Gail continued to call Kate rather than the

on-call staff at the hospice.

▪ Gail frequently said “Kate is like a daughter to us.”

▪ Kate began feeling overwhelmed by the family’s needs and pulled back by visiting less.

Gail was confused by Kate’s behavior and wondered what she had done to offend her.

▪ When John died, Kate attended the funeral. She provided 2 subsequent

bereavement visits.

▪ Gail expected Kate’s visits to continue and was surprised when they did not.

She felt betrayed that Kate didn’t stay with her after John’s death.

▪ Gail developed strong negative emotions about losing Kate’s supportive presence and

it affected her grieving process.

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We Are Family

Intention v Function: Healthcare providers are typically well-intended, but

the blurring line of a potential boundary violation can function in highly

negative ways, impacting care and healthy professional relationships.

▪ What was Kate’s intention with her behavior?

▪ How did it function for John and Gail?

▪ What were the behaviors that Kate engaged in that led to blurred boundaries?

▪ What could Kate have done to re-establish the “zone of helpfulness?”

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Case Study:

Cultural ConsiderationsRoxana is a Mexican-born hospice nurse, the only Spanish-speaking staff member. Her patient, Mr.

Martinez, a 77 year-old widowed, Mexican-born father of three who was living with his youngest

daughter prior to being admitted to the long-term care facility.

Roxana’s colleagues (social worker, chaplain, etc.) complained that she was not maintaining healthy

boundaries with Mr. Martinez and his family.

▪ The Martinez family did not maintain appointments with staff, other than Roxana

▪ Mr. Martinez did not adhere to the facility’s care regimen (e.g., meal times, etc.)

▪ When care plan meetings were scheduled, the Martinez family would arrive a half hour later,

backing up the day’s schedule. Roxana would explain that time orientation was different for

Hispanic/Latinos and the family was not intentionally being inconsiderate.

▪ Family members visited in large groups, even though the facility had a limit on the # of

visits at a time.

The family was perceived as “disruptive” by other residents. Roxana understood the cultural

dynamics and advocated for them, but the care staff accused her of “bending the rules” and having

“favoritism.”

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… Cultural Considerations

▪ What are perceived boundary violations?

▪ What are culturally related behaviors v boundary issues?

▪ How were others affected?

▪ Long term care staff?

▪ Hospice staff?

▪ Roxana?

▪ Patient/Family?

▪ What are the risks associated with having only one staff member of the

same culture/ethnicity/language as the patient and family (cultural

isolation)?

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Cultural Awareness & Inclusion

▪ When providers are of the same culture, they can easily slip into making

assumptions based on their own cultural values and preferences.

▪ It is important for the provider to individualized assessment of the patient’s

cultural norms, values, beliefs, and practices.

▪ Care plan includes sensitivity to the patient/family’s cultural beliefs,

perceptions, values and practices that may differ from the team’s culture.

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Other Boundary Issues in Disguise…I thought I was helping!

▪ Patient gives the hospice aide $20 and asks him to run to the pharmacy to

pick up medications

▪ Social worker’s husband who is a carpenter comes to the patient’s house to

repair a loose handrail on the weekend

▪ Nurse volunteers to babysit for a patient’s children to give the patient and

spouse a much-needed night out

▪ Patient is a professional musician and offers for sale his recordings; several

team members buy them

▪ Knowing the patient’s favorite food, the chaplain buys it and brings on each

visit

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What do I do when I recognize a Boundary Breach?

▪ Acknowledge it is happening and seek support from colleagues,

supervisor (self-care)

▪ Consider Self-Awareness & Self-Monitoring key questions to get to

the how and why of your actions

▪ Reset expectations with patients as to your role, availabilities, and

best way to communicate with you through the organization contact

info

▪ Proactively discuss challenges with team members and facilitate

consistent care messaging and expectations

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Boundary Breach Prevention ▪ Stay in the Zone of Helpfulness

▪ Set clear expectations with patients and families regarding:

▪ Your role in the context of care

▪ Your availability

▪ Best ways to communicate with you

▪ Consult colleagues or mental health professionals when uncertain about

your behaviors, or patient/family behaviors

▪ Address issues as they arise with patient/family

▪ Emphasize the provider-patient relationship and the importance of maintaining

objectivity

▪ Emphasize that the rejection of a requested behavior does not imply lack of caring

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Self-Care:Responsibilities & Strategies

▪ The provider’s responsibility is to delineate, communicate and maintain

boundaries → prevention!

▪ The provider works within the zone of helpfulness → prevention!

▪ Be mindful and vigilant for your own self-care and self-awareness:

▪ The provider should examine any boundary crossing, be aware of its potential implications

and avoid habitual crossings → seek support!

▪ Actions that overstep established boundaries to meet the needs of the provider are

boundary violations → remain aware and self-monitor!

▪ The provider should avoid situations where s/he has a personal or business relationship

with the patient as well as a professional one → self-monitor!

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Professional /Organizational Support

▪ Communications and ethics training & skill building

▪ Structured discussion and debriefing when a breach occurs with:

▪ Supportive non-judgmental reporting environment

▪ Understanding discussion provides a team learning opportunity

▪ Mentoring and professional supervision

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Connecting the Self to Care Outcomes

▪ Self-awareness is an important component of self-care▪ Self-monitoring is the means to identify problems early on

▪ Helps to prevent boundary breach and burnout

▪ There is an association between greater levels of awareness and a health care professional’s ability to maintain and manage emotional balance when working in difficult situations

▪ The ideal boundary “line” is what is best for the patient and the professional caregivers

▪Remember: taking care of yourself allows you to help others

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References▪ Perry, A. (2011). Crossing the line: Real stories of boundary violations and what we can learn from them. Newsline:

National Hospice and Palliative Care Organization.

▪ Sanders, S.; Bullock, K.; Broussard, C. (2012). Exploring professional boundaries in end-of-life care: Considerations for hospice social workers and other members of the team. Journal of Social Work in End of Life & Palliative Care, 8-10-28.

• Understanding Professional Boundaries. Published:28 August 2019. https://www.ausmed.com/cpd/articles/professional-boundaries. Accessed 2020.

• Professional Boundaries. CareSearch palliative care knowledge network.

• https://www.caresearch.com.au/caresearch/tabid/2752/Default.aspx. Accessed 2020.

• Self-Care. CareSearch palliative care knowledge network. https://www.caresearch.com.au/caresearch/tabid/2173/Default.aspx. Accessed 2020.

• A Nurses Guide to Professional Boundaries. (NCSBN Leading Regulatory Excellence)

• https://ncsbn.org/ProfessionalBoundaries_Complete.pdf. Accessed 2020.

• Draw the Lines: The Art of Setting Boundaries. Lizzy Miles, MA, MSW. Pallimed, a hospice and palliative medicine blog.

• https://www.pallimed.org/2014/09/draw-lines-art-of-setting-boundaries.html. Accessed 2020.

• Professional – Patient Boundaries in Palliative Care. Lise Taylor Barbour, M.D.

• https://www.mypcnow.org/fast-fact/professional-patient-boundaries-in-palliative-care/. Accessed 2020.

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