Professional Boundary Issues in Rural and Remote Settings

1. Professional Boundary Issues inRural and Remote Settings Rick Singleton Eastern Health Provincial Health Ethics Network Newfoundland Labrador

2. Agenda Short case Boundary related concepts Rural practice issues A few take aways

3. Short case Pat is registered health care professional with responsibility for child protection and other services in a rural area of the health care region. Pat was born and raised in this area and only away while at college and for the first two years of employment. Pat was delighted to move home when the opportunity came about five years ago: closer to family, life-long friends, and all interesting activities of rural life. Pat has contributed greatly to community since returning by being involved with coaching basketball at the school, being town counsellor, and lay reader at church. Lately, Pat is feeling worn down by some the current issues … Chad, a 16 year male from the area had an accident on ATV, he was brought to a larger acute care hospital. He was assessed and treated and is now ready for discharge. Pat receives a referral for follow-up with the youth. Blood work indicated the youth had cocaine and cannabis in his system at the time of the accident. What issues challenges might Pat face, if … Chad is Pat’s nephew? And/or Chad is on the basketball team? And/or The referral indicates Chad does not want his parents informed of the cocaine and cannabis? And/or Pat is uncertain whether Chad knows of the referral to Pat. Case1

4. Pat is registered health care professional with responsibility for child protection and other services in a rural area of the health care region. Pat was born and raised in this area and only away while at college and for the first tow years of employment. Pat was delighted to move home when the opportunity came about five years ago: closer to family, life-long friends, and all interesting activities of rural life. Pat has contributed greatly to community since returning by being involved with coaching basketball at the school, being town counsellor, and lay reader at church. Lately, Pat is feeling worn down by some the current issues … Pat attends bi-monthly staff meetings in the city. At the recent meeting Pat learned that the health region is planning on closing out the local clinic and services. The plan is to move the services to centralize services at a town about 35 klms away. What issues challenges might Pat face, if … Pat feels many individuals and families will not avail of services if they have to travel? And/or This move will take some jobs, both professional and support staff away from the town? And/or This matter has not been brought to the town or people? Case 2

5. Pat is registered health care professional with responsibility for child protection and other services in a rural area of the health care region. Pat was born and raised in this area and only away while at college and for the first tow years of employment. Pat was delighted to move home when the opportunity came about five years ago: closer to family, life-long friends, and all interesting activities of rural life. Pat has contributed greatly to community since returning by being involved with coaching basketball at the school, being town counsellor, and lay reader at church. Lately, Pat is feeling worn down by some the current issues … Pat has recently bumped into to Shannon a few times. They agree to get together more often as they have discovered more and more common interests … including an interest in each other. Pat first met Shannon a few years ago when Shannon was being screened to work as a respite worker with a foster child. Shannon had several interviews with Pat as part of the process. Pat was surprised when the certificate of conduct report indicated Shannon had a relevant matter on her criminal record. Pat always remembered how embarrassed and genuine Shannon was in explaining the circumstances of the case and how unfair it seemed. What issues challenges might Pat face, if … Pat buffs the shine for Shannon? And / or Colleagues and supervisors are unaware of Pat’s prior professional involvement with Shannon? And / or Colleagues and supervisors are aware or Pat’s prior professional involvement with Shannon? And / or Pat is already married? An / or Pat and Shannon are same sex? And / or Anything else? Case 3

6. Pat is registered health care professional with responsibility for child protection and other services in a rural area of the health care region. Pat was born and raised in this area and only away while at college and for the first tow years of employment. Pat was delighted to move home when the opportunity came about five years ago: closer to family, life-long friends, and all interesting activities of rural life. Pat has contributed greatly to community since returning by being involved with coaching basketball at the school, being town counsellor, and lay reader at church. Lately, Pat is feeling worn down by some the current issues … Pat enjoys the local coffee shop and bakery. Recently she had dealings with the daughter of the coffee shop owner – operator. Claire had left school due to pregnancy. Pat provided post abortion counselling and Claire has settled well and is back to school. Her parents are very appreciative. They won’t let Pat for anything at the coffee shop and bakery. What issues challenges might Pat face, if … Visits to the coffee-shop continue? Or Visits to coffee-shop discontinue? Case 4

7. Concepts Boundary: the “edge” of appropriate professional behavior, transgression of which involves the professional stepping out of the clinical role or breaching the clinical role. Boundaries define the expected and accepted psychological and social distance between practitioners and patients. Boundaries are derived from ethical treatise, cultural morality, and jurisprudence. Sometimes, it is difficult to clearly define the perimeter of these boundaries and the integrity of the relationship. What principles and concepts contribute to our understandings of boundaries? Boundary Crossing is a deviation from classical therapeutic activity that is harmless, non-exploitative, and possibly supportive of the therapy itself. Boundary violation is harmful or potentially harmful, to the patient / client and the therapy. It constitutes exploitation of the patient. Boundary Spanning is role one takes on in addition to one’s professional role, there are similar interest and goals, but not always the same.

8. Issues Geography Distance / Travel Services Options Relationships Professional / client contact outside the professional setting Desire / need of client to connect professional to self, and others in the community Know the personal and family history Multiple roles of professional SexuaL Non-sexual Culture Friendly and informal Belonging Boundaries are understood differently “[rsw] cannot easily maintain social distance from service users by relying upon a neutral or detached professional persona, for this is likely to obstruct the building of trust. It may be perceived as pompousness or insincerity, and may also run counter to local expectations” (Pugh, 2007, p. 1412)

9. Let’s compare … Advantages Rural 1 2 3 4 5 Remote 1 2 3 4 5 Disadvantages Rural 1 2 3 4 5 Remote 1 2 3 4 5

10. Multiple relationships / roles Living, working, socializing in same circles Family bonds and networks Accessing each others services Community activities and roles Friendships Feuds

11. Challenges to the Professional Learn to cope with awkward situations when the worker meets clients outside of work Personal life and lifestyle is on public display and often critiqued by the community … fish bowl effect. Used to evaluate the professionals competence, ability and trustworthiness P-Ks “For better or worse social workers hold positions that might be regarded as having some amount of moral authority or integrity. As a result, community members want to see that the social worker and members of the social worker’s family conform to a certain imagined standard” (Schmidt (2009) p. 12). If the personal life of a professional varies from this imagined standard the ramifications can be significant for one’s professional credibility and his or her ability to perform the professional role within the community.

12. Challenges 2 Building credibility and a reputable image within a community may require active participation (Zapf, 1985), but this in turn increases the likelihood of developing multiple, and sometimes conflicting, relationships. Professionalism is typified by formal roles and detached relationships, whereas rural professionals are faced with the need of having to build trust and connections. Informal networks and sources of information … gossip.

13. What helps? Ethical Principles Respect for the dignity of the patient is fundamental Autonomy, regard for self determination of the individual by establishing goals and making choices, is core Trust and good faith (the fiduciary relationship) must be maintained. A fiduciary in healthcare is one whose actions are worthy of trust. Beneficence, do good Non-maleficence, do no harm Compassion, sympathetic awareness of another’s distress and desire to relieve it. Having a system to asses the situation.

14. Considerations in Managing Boundary Challenges Gripton and Valentich’s 10 Factor Model: Vulnerability of the client Power Differences Risks for the Client Risks for the Practitioner Benefits for the Client Benefits for the Practitioner Clarity of Professional Role Boundaries Specificity or Diffuseness of Professional Roles Access to Alternative Sources of Professional Services Community Values and Cultural Norms

15. 7 C’s Clarify … roles / relationship Consult … codes, CoI policies Collaborative practice …circle of care, teams Colleagues in profession and discipline Commit to paper … document Communicate situation Competency development … for you and others.

16. Abstract and Concrete The best way to care for others is to care for yourself. Have a comfortable bed and comfortable shoes, when you are not in one you are in the other. Maintain boundaries: adhere to codes of practice and professional conduct. There’s a hair’s breath between concern and inference. People matter The rapport is more important than the report. Be honest You can’t shine sh--! Hurt people, hurt people.

17. One ship sails East and another West while the self same breeze does blow; It’s the set of the sail and not the gale that bids them where to go. So it is, as we journey on through life: It’s the set of the soul that marks the goal not the storms and the strife. John Oxenham

18. Any advice for Pat? Q / A Thank you!