The fine line between professional practice and personal interests
By Julie McStay18 Aug 2011
Nurses work closely with their patients. Those in residential and community-aged care may know their patients for months or years. Regardless, particularly when caring for the vulnerable, professional boundaries must remain firm. Health professionals need to know where the boundaries lie and recognise potential or actual violations.
In April 2011, the Queensland Civil and Administrative Tribunal (QCAT) dealt with an instance where the fine line between professional practice and personal interests became blurred.
Over nine months from June 2008, Ms Farley, a 51 year old enrolled nurse accepted gifts and money from JB, a 78 year old resident of the hostel in which she worked.
JB did not lack capacity; however, he was vulnerable due to the recent loss of his wife. He also had a habit of giving or attempting to give gifts to staff.
Ms Farley who was experiencing personal and financial problems, confided in JB. They became friendly and socialised away from the hostel. JB offered her small loans amounting to $7000 and subsequently arranged for a friend to loan her $30,000 to pay out her car finance.
In February 2009, when JB complained to another staff member that he had loaned Ms Farley money that had not been repaid, her employer commenced an investigation. The Nursing & Midwifery Board of Australia (Board) took action against her for unsatisfactory professional conduct. Ms Farley who maintained she had done nothing wrong, repaid the money and resigned shortly after.
Ms Farley argued that her intent was not dishonest; she was personally vulnerable and depressed; and the relationship with JB was personal not professional. She claimed that the acceptance of the loans had no bearing on her professional conduct.
QCAT concluded Ms Farley had breached her professional boundaries. In coming to this conclusion, it referred to the conduct and ethical standards that apply to nursing practice as encompassed in the following applicable codes and guidelines:
- Code of Professional Conduct for Nurses in Australia,
- Code of Ethics for Nurses in Australia, and
- Guidelines for Registered Nurses and Enrolled Nurses regarding Boundaries of Professional Practice 1999.
The relevant principles are:
- Nurses recognise their professional position and do not accept gifts or benefits that could be viewed as a means of securing influence or favour.
- An inherent power imbalance exists between care recipients and nurses that may make the care recipients vulnerable and open to exploitation. This power differential must be recognised and managed.
- Nurses have the responsibility to maintain this professional boundary.
- Nurses fulfil roles outside the professional role. Nurses are aware that ‘dual relationships’ may compromise care outcomes and must always conduct professional relationships with the primary intent of benefit for the person receiving care.
- Care is optimised when nurses and clients do not engage in dual relationships. Where dual relationships are unavoidable there is a potential for prejudicial practice to occur.
- Nurses should recognise that the giving and receiving of gifts and involvement in financial transactions within the nurse-client relationship has the potential to compromise the professional relationship.
Whilst QCAT accepted that Ms Farley did not have a dishonest intent, its view was that her conduct breached professional boundaries, specifically 'She developed a friendship with a patient with whom she socialised outside the therapeutic relationship. She revealed personal information to him, including about her finances. She accepted his offers to help her with her problems.'
Her conduct was 'of a lesser standard than would reasonably be expected of her by her professional peers and the public'. She demonstrated a 'lack of adequate knowledge of professional standards of conduct'. As the conduct substantially fell short of the standards expected, it qualified as misconduct in a professional respect.
Relevantly QCAT ordered that Ms Farley’s registration was to be suspended for a period of 18 months, reduced to 6 months if she undertook:
- defined sessions with a clinical psychologist, with a favourable report from the psychologist; and
- training in ethics and professional conduct.
QCAT determined that the suspension was sufficiently long to act as a deterrent to others. The conditions were framed to promote future observance of professional standards and the orders proposed considered adequate to protect the public, maintain professional standards and public confidence in the profession.
Policies, procedures and staff training
A prudent approved provider will have robust, clear policies and procedures that define the boundaries of the professional relationship. All staff must be made aware of and be trained in the policies and procedures.
Policies and procedures should reflect and reference applicable codes and guidelines, in this case, nursing codes and guidelines (see above). It is recommended that if in doubt, providers consider legal advice to ensure its policies, procedures and training programs are compliant with the laws applicable to the state/s in which they operate.
The approved provider’s expectation as to the standard of conduct of its care staff needs to be clearly stated. The policy should provide that if any staff member falls below the prescribed standard, they will be subject to internal disciplinary proceedings and may be referred to the appropriate external regulatory body.
As a minimum, a policy should state that care staff should:
- not engage in a relationship with clients outside of a professional relationship;
- regard all information provided to them by a client as confidential;
- never disclose personal information to a client unless revealing the information has therapeutic value to the client;
- never use information which they have acquired during the course of their professional relationship with a client to advantage themselves in any way;
- never withhold care from a client as punishment;
- never cause or threaten to cause pain, suffering or discomfort to a client to coerce them to act in a certain way; and
- only touch a client where the touching is necessary to administer care or is part of therapeutic treatment.
Accepting gifts beyond a small one off token of appreciation has the potential to compromise a professional relationship. It is never appropriate to accept money. Financial relationships between a nurse employee and a client are not appropriate. Personal or social relationships also potentially lead to prejudicial practice.
Given the inequality of the relationship and the vulnerabilities of the resident, appropriate boundaries must remain clear. The fine line between professional practice and personal interests must not be allowed to blur.