Professional Boundaries And Moral Obligation

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PROFESSIONAL






BOUNDARIES AND







MORAL OBLIGATION








Julie James Abdullah

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Learning Outcome















01 02 03











Explain the Relate concept of Identify mechanism

Professional culture and the for enhancing clinical
Boundaries and provision of culturally practice, professional

moral obligation in sensitive care practices and
healthcare professional

development

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Learning Outline















01 02 03











Professional Boundaries Relate concept of culture Identify mechanism for
and moral obligation in and the provision of enhancing clinical
healthcare culturally sensitive care practice, professional


• Sign of Over-Involvement • Concept of culture practices and
• Under-Involvement • Concept of culturally sensitive professional
• Self-disclosure care development
• Provision of culturally sensitive
care • CPDs
• Continual learning

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PROFESSIONAL BOUNDARIES AND



MORAL OBLIGATION IN




HEALTHCARE

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Introduction










◦ Injunctions to make the care of the patient medical staff first concern leave open

difficult questions about the boundaries of medical responsibility.






◦ How far should medical staff go in furthering the health of patients or populations for
whom they are responsible, and for which populations are they responsible and why?






◦ What are the boundaries of their responsibility, and how and where does it slip over into
something else, such as supererogatory acts or political activism?

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Introduction










◦ Moral responsibilities for individual and collective action beyond the consultation.






◦ In medicine, obligations such as acting in patients' best interests (beneficence) or

avoiding harm (non-maleficence) are more stringent than general duties that all
people have to help others and avoid harming them.






◦ To be accountable or responsible for an action, two conditions must be met.

➢First, the person must have control over the act in question. The act must be

voluntary in that they desired to perform it or could have chosen to act otherwise.

➢Second, there is a knowledge condition: to be held responsible the person must

have had the relevant knowledge to act.

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Introduction







◦ Responsibility is moral when the relevant action is one that breaches or upholds
general moral norms, such as preventing harm or promoting the welfare of others.






◦ Since medicine is a practice for protecting and promoting the health of others, it is
inherently moral and therefore entails moral responsibilities.






◦ Example


◦ A doctor who gives penicillin to a patient with meningitis who then has a severe
anaphylactic reaction. The doctor is blameworthy if they did not consult available

notes on this patient's history or ask the patient and others who might have known of

the allergy. In causing harm, they have breached their duty of non-maleficence. The
doctor could have made those enquiries, and so should have known of the allergy.

The situation changes if the patient arrives unconscious and unidentified, such that

the doctor could not know of the allergy, in which case the doctor is not held
blameworthy.

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Boundary crossings










◦ Boundary crossings are generally defined as deliberate decisions to cross an otherwise

established boundary for a therapeutic reason.


◦ These could include going out of one’s way to give a patient a more convenient
appointment time or a home health nurse performing some non-healthcare-related

task such as washing dishes or doing laundry.


◦ Accepting gifts, exchanges of personal information in order to reassure someone, or

calling to check on someone who has been discharged would also fall into this
category.


◦ Touch is another problematic issue in relation to boundaries.


◦ All of these have the potential to be unclear and to be interpreted differently

according to personal and cultural factors.

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Boundary violations










◦ Danger signals and are usually more clear-cut because they are not being done for

any reason that could be justified as “therapeutic” for the patient.






◦ These might include refusing to discharge a patient when a qualified caregiver is
available, or releasing patient information in violation of privacy regulations.

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Sign of Over-Involvement










◦ Over-involvement includes boundary crossings, boundary violations, and professional

sexual misconduct (NCSBN, 2014).






◦ Sexual misconduct is the most extreme form of boundary violation and is always
forbidden.


➢Sexual misconduct as “engaging in contact with a patient that’s sexual or may
reasonably be interpreted by the patient as sexual, and verbal behaviour that’s

seductive or sexually demeaning, or engaging in sexual exploitation of a patient or

former patient.”

➢Other activities such as kissing or discussing possible dating activity would also fall

under the sexual misconduct label.

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Under-Involvement










◦ Under involvement can include distancing, disinterest, and neglect, and be damaging

to both the patient and the nurse (NCSBN, 2014)






◦ When the nurse abandons the patient, there is a lack of care, which in turn, may be
able to increase health risks for the patient.


➢For example, ignoring the patient during two-hourly bed turns could cause bedsores
on the patient’s body or paying no attention to the patient’s strict diet could cause

food allergies.

➢Disregarding the patient is harmful to their health and may also be damaging to the

nurse.

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Self-disclosure










◦ How much personal information should you reveal at work?






◦ And how should you respond when other people "open their hearts" to you?





◦ Self-disclosure is a delicate issue.


➢If you get it right, it can strengthen relationships, instill trust, and boost self ability to
inspire and lead.






◦ But if you make unwise, inappropriate or untimely disclosures, or react badly when

others reveal personal details, it can have the opposite effect.

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Self-disclosure










◦ Example

➢Accidental nurse self-disclosure may be a facial expression the nurse gives to the

patient.

➢There are very few positive effects of nurse self-disclosure.


➢The negative results far outweigh anything positive that can come of the disclosure
and self-disclosure is discouraged.

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RELATE CONCEPT OF CULTURE



AND THE PROVISION OF




CULTURALLY SENSITIVE CARE

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Introduction










◦ Cultural sensitivity requires an awareness of cultural diversity, including how culture may

influence patients’ values, beliefs and attitudes, and involves acknowledging and
respecting individual differences.






◦ Through verbal and nonverbal communication, clinicians attempt to identify

individualised patient needs; yet, culturally sensitive communication also relies on

clinicians being able to critically reflect on their own values, beliefs, preferences and
culture, as well as understandings of traditions, perspectives and practices of culturally

diverse individuals, families and communities.

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Concept of culture








◦ “Cultural” is the adjectival of culture, referring to things related to culture.






◦ Culture is a specific individual or group's beliefs, values, norms, and life ways that can
be shared, learned, and transmitted; it influences people's thinking, decisions, and

behaviours in their everyday life.






◦ Concept of culturally sensitive care

➢Cultural sensitivity refers to health workers’ appreciation, respect, and comfort to the

cultural diversity of clients.

➢The culture of every individual cannot be assumed to be the same, and cultural

diversity is inevitable.

➢This diversity should be appreciated to achieve mutual learning for common

progress.

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Concept of culturally sensitive care










◦ The idea that one's own culture is superior to an-other's should be avoided.






◦ Respect to cultural differences is always essential to provide genuine and satisfactory

care for clients.





◦ Both appreciation and respect are based on feeling comfortable within this cultural

diversity instead of false flattery to other cultures

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Provision of culturally sensitive care










How to Implementing Culturally Competent in Nursing Care?






1. Knowledge of Cultures





◦ Healthcare provider shall gain an understanding of the perspectives, traditions, values,

practices, and family systems of the culturally diverse populations for whom they

provide care, as well as knowledge of the complex variables that affect their
achievement of health and well being.

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Provision of culturally sensitive care










2. Education and Training in Culturally Competent Care






◦ Healthcare provider shall be educationally prepared to provide culturally congruent

health care.





◦ Knowledge and skills necessary for assuring that care given is culturally congruent shall

be included in global health care agendas that mandate formal education and
clinical training as well as required ongoing continuing education for all health

practitioner.

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Provision of culturally sensitive care










3. Critical Reflection


◦ Healthcare provider shall engage in critical reflection of their own values, beliefs, and

cultural heritage in order to have an awareness of how these qualities and issues can
influence culturally congruent health care.






4. Cross-Cultural Communication


◦ Healthcare provider shall use culturally competent verbal and nonverbal
communication skills to identify client’s values, beliefs, practices, perceptions, and

unique health care needs.

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Provision of culturally sensitive care










5. Culturally Competent


◦ Healthcare provider shall use cross-cultural knowledge and culturally sensitive skills in

implementing culturally congruent health care.





6. Cultural Competence in Health Care Systems and Organizations


◦ Health care organizations should provide the structure and resources necessary to

evaluate and meet the cultural and language needs of their diverse clients.

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Provision of culturally sensitive care














7. Patient Advocacy and Empowerment


◦ Healthcare provider shall recognize the effect of health care policies, delivery systems,

and resources on their patient populations and shall empower and advocate for their
patients as indicated.


◦ Healthcare provider shall advocate for the inclusion of their patient’s cultural beliefs

and practices in all dimensions of their health care when possible.

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Provision of culturally sensitive care










8. Multicultural Workforce






◦ Healthcare provider shall actively engage in the effort to ensure a multicultural

workforce in health care settings.





◦ One measure to achieve a multicultural workforce is through strengthening efforts of

recruitment and retention in health care organizations and academic settings.

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Provision of culturally sensitive care










9. Cross-Cultural Leadership






◦ Healthcare provider shall have the ability to influence individuals, groups, and systems

to achieve positive outcomes of culturally competent nursing care for diverse and
vulnerable populations.






◦ Healthcare provider shall have the knowledge and skills to work with public and private
organizations, professional associations and organizations, and communities to

establish policies and guidelines for comprehensive implementation and evaluation of

culturally competent care.

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Provision of culturally sensitive care










10.Evidence-Based Practice and Research






◦ Healthcare provider shall base their practice on interventions that have been

systematically tested and shown to be the most effective for the culturally diverse
populations that they serve.






◦ In areas where there is a lack of evidence of efficacy, Healthcare researchers shall
investigate and test interventions that may be the most effective in reducing the

disparities in health outcomes.

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IDENTIFY MECHANISM FOR




ENHANCING CLINICAL PRACTICE,



PROFESSIONAL PRACTICES AND




PROFESSIONAL DEVELOPMENT

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CPDs










◦ A lifelong process of active participation healthcare/nurses in learning activities to help

them maintain their continuing competence, enhance their professional practice and
support achievement of their career goals.






◦ It involves building on the educational and experimental bases of healthcare across

their professional careers with the main aim of ensuing quality of health care to the

public.





◦ Healthcare who are motivated and seek continuous education voluntarily mainly do so

far for personal purposes, self improvement, to increase knowledge in their specific

fields or to remain current in their practice

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CPDs














Methods of CPD






1. Personal Planning

◦ Identify own needs; conduct self-evaluation / assessment


◦ Determine professional goal


◦ Determine methods to achieve this goal


◦ Select a suitable learning opportunity

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CPDs










2. Take an interval inventory






◦ Internal inventory can be done annually or at the end of the year, but there are some

disadvantages of doing it.





◦ Assess CPD needs according to immediate, short-term and long-term planning.

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CPDs














3. Being informed and anticipating change


◦ Understand your work environment and ability to anticipate changes.


◦ Workplace provides valuable information about information about the support that
can or cannot expected from the employer.


◦ Be aware and anticipate change in the health care system.


◦ Advancement in technology and changing structure of healthcare.

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CPDs










4. The written word






◦ Reading journals eg; nursing journals provides insight info nursing professional trends,

issues and current practices.





◦ Another source of information is the internet. The advantage - speed information can

be available and the growing ease with which it can be accessed. The time gap of the
traditional publishing process has diminished considerably.

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CPDs










5. Interpersonal networks






◦ It can be formal or informal and involves person to person contact - opportunities to

discuss ideas and concepts and access information which is not found in journals.
Expert






◦ Chatting on the internet with authors, content experts and peers whom cannot meet
for certain reasons.






◦ Platform for internet communication is easily accessible from industralised countries but

not developing countries.

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CPDs










6. Professional Workshop and seminar






◦ Benefits of attending professional workshop and seminar


➢ Earn contact hours for licensing.


➢ Opportunity for interpersonal networking.

➢ Widen networking through international conferences


➢ Learn new skills or technology in healthcare.

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CPDs














7. Professional Organization






◦ Improved knowledge by working with experts or through newsletter or journal.

➢by actively participating in a professional organization and working on a committee,

one can step into a unique level of professionalism

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CPDs










8. Formal Professional courses






◦ Register for professional course(CPE) such as critical care nursing, orthopedic nursing

and others





◦ Attend post-registration of advance diploma courses for more comprehensive

knowledge and specialized skill for paramedics






◦ Improves competency towards professionalism progressed to tertiary level

➢Necessary for nurses to upgrade to baccalaureate and even to doctoral level.

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CPDs














◦ The Impact of CPD





➢Vital to improve the healthcare of the public and improve the quality of care for patients




➢Awareness of professional issues, improved self-confidence and a greater ability to think
critically about all aspects of clinical practice. – enhance motivate their career development.

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Continual learning










◦ Continuing learning are intended to develop, maintain, and improve competence in

practice, teaching, research, and/or policy.





➢The healthcare delivery system is constantly changing; populations are more diverse

than they were just 10 years ago in every sense.




➢In addition, the requisite knowledge and skills required for practice, education,

research, and advocacy, continue to expand.

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Continual learning










◦ Recommendation is to ensure that healthcare staff engage in lifelong learning,

whether they are students, faculty, clinicians, administrators, or others.






◦ Healthcare staff should achieve higher levels of education and training through an
improved education system that promotes seamless academic progression.






◦ Example:

➢How many nurses have taken the long route to attaining a terminal degree from

diploma RN, to associate degree RN, to bachelor's degree RN, to master's degree
RN and possibly advanced practice registered nurse (APRN), to doctoral prepared

RN? How many years and nursing programs were involved to complete the journey?