Professional Nursing Boundaries In Haemodialysis Essay

Introduction

Professional nursing boundaries are elements used by nurse professionals to help defiant their roles and interactions as they relate with patients. Professional boundaries allow safe and efficient personal connection between nurses and patients (Baca 2011). Holland defines professional nurse boundaries as unspoken physical and emotional laws understood by all nurses limiting the relationship between patient and the nurse (2012). The United States Department of Health and Medical services gives nurses roles to ensure patients receive quality health care at all times irrespective of the relationship with the care giver. Additionally, nurses are obliged to follow the nursing rules and regulations. Professional boundaries in nursing makes a caregiver face a patient as a victim and any business apart from provision of health care services should be conducted outside the health care facility. In every health care setting, a patient expects the nurse to respect his or her dignity and show respect while offering medical care services (National Council of State Boards of Nursing 2014). Below is a case scenario of a nurse who crossed professional boundaries by favoring a friend in injection of intravenous iron drugs during haemodialysis treatment process.

A case scenario of professional nursing boundaries

There are numerous examples of cases where nurses find themselves violating the rule of professional boundaries. For example, there was a case of crossing professional boundary in the health care facility during intravenous administration of iron in a patient during the haemodialysis process. Haemodialysis is the process of removing drugs from the blood that passes through the dialysate membrane (McKay, Reid, & Walters 2010). The process is very sensitive and requires a lot of expertise to conduct. Nurses are trained to have a therapeutic relationship with patients, which give the nurse knowledge, abilities, and skills towards meeting the health needs of a patient. Practicing nurses are expected to get an approval from a physician before giving any intravenous injection to a patient. According to Nursing & Midwifery Council (2010), two nurses must check any medication administered intravenously, one a registered practitioner and who administers the drug. The nurse practitioner had graduated four months ago and was already giving intravenous drugs to a patient with chronic kidney failure because he was a friend.

How did it happen?

Every nurse understands guidelines for professional behavior because they are taught in nursing institutions and while in the practice of nursing. Professional nurses have invisible lines primarily drawn to protect patients and any person in the practice on nursing who crossed this line violates nursing professional rules. Administration of intravenous drugs to a patient is a very crucial procedure that requires a lot of proficiency. During administration of intravenous iron to haemodialysis patient, the professional is expected to follow five major steps: Assessing the patient, make sure the surrounding environment is favorable for drug administration, follow treatment plan, administer the drug, and ensure follow up care (ANSA n.d). In the following scenario, the nurse did not bother to follow the steps required and ended up affecting the patient’s treatment process. The patient was a friend to the nurse, which made the nurse to go on with the treatment process without notifying the relevant authority. Step four of intravenous iron drug administration requires that the person administering the drug be a registered nurse, and competent at administering intravenous drugs (Nursing & Midwifery Council 2010). Professional nursing boundaries restrict nurses from favoring patients in need of care regardless of the relationship with the nurse or physician.

The possible effects of crossing boundaries to the client

According to Harper (2013), the frequency and duration of dialysis treatments contributes to strong personal relationship between the nurse and the patient. The patient is most likely to suffer a long-term effect because the treatment process was not cross-checked by a qualified physician. The process resulted into medical errors because the patient was not injected with the correct dose of iron causing prolonged illness. The patient may suffer long-term psychological help when one fails to get solution to the problem at hand. Additionally, the patient develops impaired ability to seek medical help from other nurses (Royal College of Psychiatrists 2013). According to Davita dialysis experts (2015), nurses should be extremely careful when carrying out dialysis plan and it should occur in a clean area. The patient may experience slow heart rate more often, shortness of breath, and may result to dizziness, headache, and low blood pressure. Other adverse effects to the patient include worsening kidney function, and major erectile dysfunction.

Concepts of boundaries-crossing/blurring of boundaries

Researchers have conducted numerous studies in an effort to discover the impacts of crossing professional nursing boundaries on the client. According to the College of registered Nurses of British Columbia, nurse-client relationship forms the primary foundation of nursing across all cultures and population in every practice settings. Nurses are obliged to follow professional nursing rules irrespective of the profession, power, hierarchy, culture, and gender. Outcomes of these studies show that the concept of boundaries-crossing has significant effects on inter-professional working relationship, hierarchy, vertical and horizontal professional blurring, and many others as discussed in the following literature.

Inter-professional working relationship

Boundary crossing has significant outcomes on inter-professional working relationship. Aase, Hansen, and Aase (2014) conducted a qualitative study to investigate the perception of inter-professional teamwork. The study aimed at determining how nursing and medical students understand their roles as professional health care providers in terms of professional boundaries and teamwork. The study was conducted on Norwegian students of nursing and medicine. Boundary crossing interferes with inter-professional relationship because teammates evade working with nurses accused of violating boundary rules. Outcomes of the study revealed that most institutions utilize traditional patterns of professional role. The role ensures nurses and medical professionals take responsibilities across all disciplinary and professional boundaries. On the other hand, nurses should be more focused on inter-professional teamwork and avoid working as individuals because it encourages violation of professional boundary act.

Power and hierarchy

Nursing profession like any other career is made up of people occupying different posts in depending on power and hierarchy. The professional boundary rule does not consider power of hierarchy of an individual because all have a common goal of delivering quality care to patients. Vuolanto (2013) used the theory of scientific boundary-work: concept and approach to study the impact of power and hierarchy of nurse professionals in respecting boundary regulations. The theory seeks to reveal hidden power structures and hierarchies on the context of nursing science. The study discovered four primary forms of boundary-works that determine influence power and hierarchy in nursing. Power and hierarchy introduces major conflicts of interest where those in power think they have the right to cross professional boundaries and abuse patients. Additionally, the issue of politics and the position held in the society was identified to accelerate boundary-crossing cases in healthcare industry. Vuolanto’s study played a critical role in exploring neglected areas in nursing that limit achievement of health care goals. In relation to the above scenario, the nurse ignored the rules and protocols followed in administering drugs to patients and took advantage of his position to cure his friend.

Vertical and horizontal professional blurring

In United States, the nursing is ranked among the most respected professional from annual national polls conducted each year. The ranking of the professional as the most respected and widely trusted shows a special relationship which occurs between nurses and patients (Riffkin 2014). Vertical and horizontal professional blurring results into senior nursing professionals using their positions to abuse patients by asking them sexual favors, monetary gains, and other activities that go against the nursing codes of ethics. Bullying in health care industry is common horizontally (between colleagues) or vertically (between nurses and patients) and results into violation of professional boundary rules. The State of Ohio developed a Standard Care policy that provided guidelines on how nurses should carry themselves in presence of other colleagues and clients. The state health care sector had experienced many cases of harassment. The major causes of vertical and horizontal professional blurring are lack of understanding ones’ roles in the practice, inappropriate empowerment, and lack of accountability (DeVore 2012). The nurse found guilty of engaging the client to sexual acts lacked accountability and proper empowerment. Eagar (2010) argued that lack of effective communication and motivation programs are major causes of violation of professional boundaries experienced in the health industry.

Occupational culture, gender dominance, ethical principles

Culture and ethical principles plays a major role in shaping the practice of nursing. Nursing culture requires all practicing nurses to demonstrate ethical behavior in the presence of other nurses and patients. Nurses are obliged to follow the laid down procedures while delivering care to patients and not be overcome by feelings or any other issue capable of making someone cross professional boundaries. Political, social, and economic transformations in the present society lead to uncertainties, ambiguities, and instabilities in the health care industry. People no longer respect the traditional nursing culture expected on professional groups. Carvalho conducted a study to investigate changing connections between professionalism and managerialism in Portugal. The research found out that nurses in Portugal managed to develop hybrid professionalism through incorporating cultural values and norms in the practice (Carvalho 2014). Gender dominance and dynamics have little influence on the delivery of care; they only assist in separating nursing according to stereotype for easier recognition in management field. According to Anderson (2014), challenges occur when men are engaged with female clients for longer periods.

Implications and recommended solutions to the scenario

The scenario presented above was a total violation of professional nursing codes of ethics in boundary regulations. The nurse was supposed to follow clinical procedures outlined in a dialysis treatment program and ignore the relationship they had with the patient. Additionally, presence of the scenario was an implication that most nurses never take their work seriously and are more concerned about individual achievements rather than quality care. Aase, Hansen, and Aase’s study indicated that lack of adherence to traditional nursing practices contributes to nurse-patient relationships experienced in healthcare industry (2014). On the other hand, poor inter-professional and intra-professional relationships are major sources of nurse-patient relationships. The nurse did not involve his colleagues, who are registered and experienced in administering intravenous drugs, into the action. According to McGowan, nurses must adhere to legal and ethical duties in their professional role, which include maintaining patient’s confidentiality and privacy (2012).
The public expects to trust caregivers with private information but when boundaries are crossed trust ceases (Nursing and Midwifery Council 2013). The above scenario demonstrates lack of seriousness in the profession. Schools of nursing should thoroughly prepare graduates to the task. Nurse practitioners and physicians should adhere to rules and regulations of the industry. The nurse in the scenario should undergo a severe punishment to act as a lesson to others with similar behaviors. Additionally, the federal state health department should introduce huge penalties for practitioners found guilty of crossing professional boundaries. The scenario also showed ignorance from the hospital management by allowing a new graduate to attend to patients. New graduates should work under close supervision in order to ensure they give the correct medication and at follow correct treatment procedures.

Conclusion

Every professional nurse has a daily responsibility of setting boundaries with patients since it assists in many practices especially dialysis where a nurse spends a lot of time with one patient. Allender, Rector, & Warner (2010) argued that nurses have a role to play in maintaining a healthy society. There is higher likelihood of violations and crossing of professional boundaries especially where a patient is a family member, close friend, or a powerful person in the society in terms of wealth, politics, or social class. Nurses should train themselves into avoiding instances that may make one lose the job or cause more harm to the patient. The discussion helps both professional nurses and patients to understand professional boundaries and identify circumstances that may lead to violation of the boundary.

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