Professional Boundaries: A Matter of Therapeutic Integrity

Female filicide perpetrators: challenges facing clinicians and secure services

Much exists in the literature on filicide and the characteristics of perpetrators and their victims but there is little in the way of practical advice on how to manage perpetrators of filicide in secure psychiatric wards. Clinically, these patients can rapidly respond to medical treatment, only to be faced with the reality of what they have done. In the authors' experiences, certain aspects of their management are particularly challenging due to the emotive nature of their offence. These include managing the interpersonal dynamics on a ward, the media interest that surrounds the case and rehabilitation back into the community. In this article we outline a brief background to filicide in the context of mental illness and describe our experiences of managing the practical difficulties outlined above. The approaches used, outcomes and the supporting evidence base are discussed and illustrated through examples.

"We Deal Here With Grey": Exploring Professional Boundary Development in a Forensic Inpatient Service

BACKGROUND

Maintaining appropriate professional boundaries with clients in mental health settings can be complex, particularly for forensic inpatient nurses and healthcare workers. The literature in this area has mainly focused on boundary violations, with little research on how staff members develop and maintain boundaries in forensic inpatient units, despite safe working relationships being beneficial for staff experience and client recovery.

METHOD

Interviews with 11 nurses and healthcare workers from forensic inpatient wards were analyzed using a constructivist grounded theory methodology.

RESULTS

A cyclical model of boundary development was developed in which staff initially acclimatize to the forensic environment before entering a calibration phase of constantly assessing and addressing professional boundary issues in daily working life. Staff members use this experience alongside reflection, social learning, and clinical supervision to undergo individual learning and team development. In the fourth phase, they use this learning to recalibrate their views on boundaries, themselves, and how they work with clients. This recalibration impacts on staff members' further management of daily boundaries, providing more materials for learning, which leads to further recalibration.

CONCLUSIONS

This study echoes previous literature suggesting the importance of supervision and reflective spaces in professional boundary understanding. The model is comparable with existing learning theory and reflects a clinical drive toward safe uncertainty. The importance of social and experiential learning is highlighted and has important implications for forensic nurses.

Do professional boundaries limit trust?

The present study uses stories of mental health support workers talking about their relationship with clients to wonder about how trust might be limited by the professional boundaries of nursing. The writing arose out of an appreciative inquiry study looking at the role of mental health support workers. Participants talked about how they worked with their clients. As researchers, we were struck by the depth of trust that was built between worker and client. We have brought a phenomenological lens to wonder about the nature of trust, as shown in the data. The original research sought to identify what was working well for mental health support workers. The present study brings a phenomenological interpretive approach to four stories from the discovery phase of the study, with our thinking informed by Heidegger and van Manen. Interviews were conducted with 26 mental health support workers and six stakeholders in 2012-2103. For this paper, we drew from those transcripts stories of three mental health support workers and one stakeholder. Through a process of talking together, writing, and rewriting, we wondered about the meaning within these stories, with a strong focus on how trust was enacted. We saw that mental health support workers in this study, by not carrying the boundaries of being 'professional', seemed free to grow a stronger relationship of trust which was therapeutic. We ask: Is it time to rethink how professional boundaries limit the level of trust achieved with clients to the detriment of impactful care?

Whistleblowing and Boundary Violations: exposing a colleague in the forensic milieu

The purpose of this article is to examine the phenomenon of whistleblowing as it relates to a reconstructed case study of an erotic boundary violation that emerged from a clinical situation in forensic psychiatric nursing practice. The unique features of this case are illustrated with the help of a model for decision making. Although the ramifications of exposing a colleague are many, it is argued that, in this particular case, it was morally and ethically the right thing to do.

Elders adapting to a chronic diagnosis within a nursing refuge

The increasing numbers of people seeking care for chronic disease has placed unparalleled demands on nurses who journey with them as they grasp the meaning of their altered health status. The complexity of the newly diagnosed chronic disease can be overwhelming. Newly diagnosed elder patients need a refuge in which to explore the uncertainties and challenges in managing a chronic illness. Reactions to a new diagnosis are uniquely shaped by the elder person's culture, age, life circumstances, and previous coping strategies. Six dichotomous response pairs are posed: relief versus devastation, courage versus cowardice, disease obsession versus disease aversion, rational thinking versus intuition, reawakening versus stuck, and self-reliance versus dependence. Nurses can create a sanctuary for elderly patients with protected space, presence, partnership, past to future orientation, and perspective on life. Nurses who embrace this mission may find themselves returning to the reasons they sought a nursing career, to support and strengthen elderly people in the most vulnerable moments of their lives.

"You feel like family..." professional boundaries and social model aphasia groups

In this theoretical paper, we argue that the adoption of the social model to aphasia rehabilitation within group settings changes the metaphorical location of the boundaries between clinicians and clients. Despite a growing literature on group work for aphasia and social model applications for people with chronic aphasia, there has been almost no attention paid to how professional boundaries are negotiated. This paper reviews how this issue is dealt with within professional codes of ethics and what is written more broadly on professional boundaries, and then uses a number of real case examples to encourage further discussion and awareness of this important issue in aphasia rehabilitation within group settings.

Frequency of postlicensure registered nurse boundary violations with patients in the state of Ohio: a comparison based on type of prelicensure registered nurse education

Nurse-Patient boundary violations remain a problem. Efforts to address the problem through postlicensure education and stronger disciplinary measures are well documented. However, efforts to understand this problem based on prelicensure components are less studied. Using data from The Ohio Board of Nursing from 2002 to 2006, the difference in frequency of incidents of violations between associate degree-prepared registered nurses and baccalaureate degree-prepared registered nurses was studied. A statistically significant difference was found through chi-square analysis: Associate degree-prepared nurses had higher frequency of boundary violations. Further studies on prelicensure curricular influences on registered nurses' postlicensure behavior, particularly in relation to curricular content focused on interpersonal skill development, are recommended.

Exploring boundaries in the nurse-client relationship: professional roles and responsibilities

TOPIC

The creation and maintenance of boundaries as they pertain to the nurse-client relationship.

PURPOSE

To challenge readers to reflect on their fiduciary responsibilities by identifying boundary crossings and violations.

SOURCES

Review of the literature and the authors' clinical and teaching experiences.

CONCLUSIONS

Although self-awareness and monitoring, debriefing, and availing oneself of supervision and education are important tools in creating and maintaining boundaries, in the final analysis, the nursing profession needs nurses who have the ability to make decisions about boundaries based on the best interests of the clients in their care.