Boundary Violations

There are a number of boundary violations:

  1. Developing Friendships
  2. Gifts and Favors
  3. Self-Disclosure
  4. Dual Relationships
  5. Intimate Relationships

1. Developing Friendships

There is no question it can be hard to keep proper boundaries with your patients in light of how much time you spend with them. You get to know them on a personal level and work with them during a very difficult and trying time of their lives. You learn about their families, careers, interests, goals, hopes, and fears. You are afforded access into their private lives in a way that is generally reserved for loved ones and friends, not healthcare professionals.

Here is where you need to draw the line between a friendship and a caring professional relationship. As a PCT, you learn a lot of personal information only because patients need to come to your clinic for treatment. This is not a relationship built on mutual give-and-take. Rather, it is a professional relationship that should be built on the needs of the person with kidney disease. Boundary violations occur when you start to spend personal time with a patient outside of the clinic. Beware of going to parties, weddings, or playing any role that moves your relationship with a patient toward a friendship. Remember, you can be caring and “friendly” with your patient without turning the relationship into a friendship.

2. Gifts and Favors

Gifts and favors are two trouble spots in many healthcare settings, and dialysis clinics are no exception. Many clinics have a policy on taking gifts. If yours doesn’t, it would be a good idea to think about suggesting one. A no-gift policy is one of the best ways to protect staff against being accused of playing favorites. For example, if a patient brings food for the whole unit, problems can occur. Other patients might not be able to afford to bring in treats for the staff, and they might think that since they can’t bring in treats, they won’t be treated equally.

When a patient offers a gift, it is most likely meant as a simple token of thanks. But in some cases when a patient wants to give you a present, it can have hidden meaning that you aren’t aware of. Patients may think, for example, that giving a gift will bring them a higher standard of care or maybe get them on and off the machine first. If other patients see you take a gift, they may feel pressure to give you a gift, too. Or, a gift giver might have romantic feelings toward you—and taking a gift may signal that you want to have a relationship. Rather than taking gifts, ask patients to thank the whole clinic with a card or a heartfelt letter instead.

Doing favors or “playing favorites” can also cause a great deal of trouble in the dialysis clinic. A good rule to keep in mind when doing something for a patient is to ask yourself:

  • “Would I do this for EVERY patient?”
  • “Would I feel comfortable telling a room of my peers what I did.”

If you can’t say yes to both questions, you may be giving special favors or playing favorites. It is easier for us to like some people more than others, but we still need to treat all patients fairly. Following your clinic’s policies and procedures is a good way to make sure you are providing equal care for all patients.

3. Self-Disclosure

Your patients have many challenges to face. Sharing some of your own challenges may help them. For example, you might have had a hospital stay and gained some insight into a treatment that might help a patient. However, you need to look closely at how and what you choose to share about yourself, your background, and your life. Ask yourself these 3 questions when you think about what to share with a patient:

  • “Why am I sharing information with this patient?”
  • “Is the information going to help a patient, or is it more about me?”
  • “Does this disclosure seem more like something I would share with a friend?”

As you think about what to tell patients about yourself, keep in mind that self-disclosure should be rare and should not have personal details. Stick to general events. If you find yourself feeling an emotion (guilt, anger, sadness, etc.) when you tell a patient a fact about yourself, this is a sign that what you are sharing is too personal—and is not being shared for the benefit of the patient.

4. Dual Relationships

A dual relationship occurs when you are involved in more than one aspect of your patient’s life. In small communities this can be a challenge because you may go to the same church, have kids in the same schools, or spend time with some of the same friends. If this is the case for you, it is even more critical for you to recognize and address these relationships. In most cases you, as the professional, can choose to not enter into a dual relationship with your patient.

An easy example to use to describe a dual relationship is fundraisers for schools. Your child is selling gift wrap and you have 150 patients in your clinic who may need wrapping paper. However, what you’re doing is creating a new relationship with your patients where they are buyers and you are a seller. As you can see, this relationship has nothing to do with dialysis care and it is a clear boundary violation.

5. Intimate or Sexual Relationships

In many ways, having a sexual or intimate relationship with a patient might be the most serious of all boundary violations. We have heard things such as “fate brought us together” and “it was impossible not to fall in love,” but these do not explain away the ethical and boundary issues involved in this type of relationship. People who need dialysis are vulnerable. You, as the professional, are in a position of power and authority based on the knowledge you possess and the resource you control, namely the dialysis. To take advantage of your position by starting an intimate relationship is unprofessional, unethical, and a clear boundary violation.