Recognition and respect of professional relationship boundaries compose a vital element of medical practice and clinical practice in particular. Professional-patient boundaries in clinical practice relate mainly to different physical assessment skills and methods, and acts of care for the patients. Multiple issues raise awareness on the subject of professional boundaries in clinical practice and the prevention of potentially harmful violations of boundaries. Analyzing different surveys on various approaches to professional boundaries could help to explore possible ways to legally prevent boundary violations in clinical practice.
The original concept of boundaries was introduced in the Hippocratic Oath and implied that physicians must maintain confidentiality and follow the principles of beneficence and nonmaleficence. The Oath partially mentions the potential issues and notes that the physician is to enter the patient’s house only for the patient’s good and must keep himself from all ill doings and seduction (Friedman & Martinez, 2019). Since then, society has made numerous attempts to define the boundaries and protect them through various professional codes, such as the American Medical Association (AMA) Code of Ethics. The Code of Ethics includes three sections that cover the topics of patient-physician interactions, treatments and technologies used in treatment processes, and a self-regulation code for professionals. Several peer review committees and institutional lawyers reviewed different types of potentially inappropriate relationships between the professionals and patients to avoid violating professional boundaries. According to Nieva et al. (2019), professionals were recommended to maintain “arms-length” postures in the process of patients’ examinations. However, as a result of the changes, some of the professionals reported patients’ growing alienation from the physicians.
Several different programs are implemented in the modern world aimed at training the students based on professional boundaries; for example, in the UK, the training involves the use of simulated patients (SPs). SPs are used to train and educate the students in a supportive environment by providing feedback in ‘intimate’ examinations and improving students’ clinical skills and confidence (Kearney et al., 2018). However, Kearney et al. (2018) also emphasized that the power dynamic between physicians and patients during examinations could be very intimidating to the patients and influence overall opinion about the treatment. As the same dynamic is present in the training processes that involve SPs, there are several ethical concerns about the impact the training makes on their emotional stability and the overall use of the method.
As few counties use methods like the involvement of SPs, the learning process of professional boundaries in several countries entirely relies on educational programs. In the study conducted by AlMahmoud et al. (2020), the authors provided data from interviews of over a hundred medical students in their final years in the UAE. The data provided by the students indicated that medical education does not play a significant role in dealing with ethical conflicts. Moreover, the students expressed frustration about the quality of education and training in the fields of medical ethics and relationship boundaries.
There could be several collateral reasons for the violation of boundaries in clinical practice. For example, the study conducted by Raleigh and Allan (2017) focused on the subject of physical assessments performed by nursing personnel indicating that violation of boundaries could happen due to the time-pressured environment of clinical sites. The study pointed to the shortage of adequate resources to provide patient-centered assessments (Raleigh & Allan, 2017). The authors emphasized that meeting the standards for consistent care could potentially face barriers of conflicting organizational and strategic initiatives.
The survey conducted by Nieva et al. (2019) counted more than seven hundred responses from primary care physicians involved in the process of treating adults. The survey results showed that a broad sample of the respondents perceived crossing of boundaries as acceptable, and many of the respondents acted similarly in their practices. Moreover, a significant part of the respondents stated that although they have done multiple boundary crossings in their practice, only a few patients expressed their disagreement with the professionals and proceeded to file a complaint.
Compiling the results of the surveys, one could address the unsafety of patients’ boundaries and the need for education of the medical personnel on the theme of boundaries in relationships with patients. The education should also include other valuable aspects that influence the clinical practice. For example, Slobogian et al. (2017) expressed that the use of social media by healthcare professionals threatens professional boundaries and implies a risk to a professional image. All of the issues highlight the need to develop an approach to professional boundaries based on strict rules. The development of strict codes of professional boundaries would solve the problem of medical students being frustrated with the quality of education on the topic of professional boundaries. The strict rules could also help to fix the collateral reasons for violation of boundaries, like the problem of timing in clinical practice. Furthermore, the introduction of the code would make the physicians understand the impact of their actions and realize their responsibility for the patients’ comfort.
In conclusion, this research paper focused on exploring legal methods to prevent violation of professional boundaries through analysis of different surveys on the topic of boundaries in clinical practice. The research showed that violation of boundaries in clinical practice happens majorly in the processes of physical examinations. Therefore, addressing multiple issues within the examination processes requires developing a strict code of rules on professional boundaries and relationships between the professional and the patient.
References
AlMahmoud, T., Hashim, M. J., Naeem, N., Almahmoud, R., Branicki, F., & Elzubeir, M. (2020). Relationships and boundaries: Learning needs and preferences in clerkship medical environments.PloS one, 15(7), e0236145.
Friedman, S. H., & Martinez, R. P. (2019). Boundaries, professionalism, and malpractice in psychiatry.Focus (American Psychiatric Publishing), 17(4), 365–371.
Kearney, G. P., Gormley, G. J., Wilson, D., & Johnston, J. L. (2018). Blurred boundaries: sexuality and power in standardized patients’ negotiations of the physical examination. Advances in simulation (London, England), 3, 11.
Slobogian, V., Giles, J., & Rent, T. (2017). #Boundaries: When patients become friends. Canadian oncology nursing journal = Revue canadienne de nursing oncologique, 27(4), 394–396.
Raleigh, M., & Allan, H. (2017). A qualitative study of advanced nurse practitioners’ use of physical assessment skills in the community: shifting skills across professional boundaries.Journal of clinical nursing, 26(13-14), 2025–2035.
Nieva, R. H., Ruan, E., & Schiff, G. D. (2020). Professional-patient boundaries: a national survey of primary care physicians’ attitudes and practices. Journal of general internal medicine, 35(2), 457–464.