Professional Boundaries In Mental Health Nursing Essay.

Selecting Priorities to Effectively Reflect Nursing Practice

Boundaries play an essential role in providing a sense of authentic control in a relationship. Professional boundaries refer to the limits that are present in the relationship of a person being provided care and the concerned nursing professional, which in turn provides an opportunity for the establishment of a therapeutic and safe connection between them. Effective management of the boundaries in mental health nursing encompasses the need of giving satisfactory attention to the question of role management (Langendyk, Hegazi, Cowin, Johnson & Wilson, 2015). A role boundary clearly defines the rights, duties, and limitations of the healthcare professionals involved in delivering optimal mental care services to the clients. Nurses enter a therapeutic relationship with necessary knowledge and skills that consist of gaining an understanding of the personal information about the client being provided their services. Presence of a caring relationship between the nurse and the patients admitted to mental health settings are considered as an essential component, facilitating the recovery of the patients.

The professional boundaries make the nursing professionals work with the aim of providing a trustworthy and reliable foundation that would enable effective therapeutic interaction with the clients (Niezen & Mathijssen, 2014). The dignity, privacy and autonomy of a client is commonly safeguarded within an operative nurse-client relationship. Any nurse found to participate in activities that violate the professional boundaries directly threaten the relationship with the service users. The essay will discuss the professional boundaries that impact the nurse-client relationship and will elaborate on it in the context of legal, ethical and professional issues.

Professional boundaries acts as a framework for the development of healthy relationships between the patients and the healthcare providers. These boundaries act as emotional and physical limits that protect the vulnerability of all the service users. This professional boundaries help in maintain a focus on the client. Mental health providers are required to abide by the professional boundaries that make them protect and safeguard the trust of their clients and their family members, while providing careful attention to the relationship that exists between them. The providers also have the duty of respecting how the healthcare experiences o their clients create an impact on feelings associated with personal power. Owing to the fact that mental health providers have an authority in the relationship, they are directly responsible for management of the existing boundaries. The power of a mental health nurse essentially comes from their professional position and the access that these nurses have to the personal information of the clients, which in turn is imperative for the treatment of a prevailing mental health condition. In other words, professional boundaries refer to certain spaces that exist between the power of mental health nurses and the vulnerability of the clients. These professional boundaries have been proved effective in the formulation of a zone of helpfulness, thereby allowing the development of a safe association between the mental health nurse and the client. A range of behaviours or continuum help in defining these boundaries in a mental health setting. A zone of helpfulness is where mainstream interactions occur for success the safety of the patients. While over-involvement involves boundary violation and crossing in the form of inappropriate relationship and sexual assault, under-involvement includes coldness, distancing, and neglect.

Understanding Professional Boundaries in Mental Health Nursing

Patients have been usually found to trust their healthcare professionals owing to the latter’s competence, dependability, truthfulness, and compassion. According to Section 8.2 of the code formulated by the government of Australia, professional boundaries are considered imperative for an effective relationship between the service users and the professionals and the latter has the responsibility of promoting good care and protecting the integrity and dignity of the patients. Thus, good medical practice most commonly encompasses the act of maintain professional boundaries and prevents all nursing professionals from using their position to establish any sort of exploitative, sexual or inappropriate relationship with patients who have been admitted to the mental health wards. Sexual misconduct can be referred to as an extreme kind of professional boundary violation that are serious breaches of the professional responsibility of nurses in the form of behaviour that are sexually demeaning, seductive or harassing.

Five components govern the establishment of a nurse-client relationship that directly contribute to the wellbeing and enhanced health of the clients. This relationship is grounded on respect, power, trust, empathy and professional intimacy (Campbell, Yonge & Austin, 2016). Furthermore, it also requires fitting use of authority and power that is inherent to the role of a care provider. These five components regulate mental health nursing, regardless of the background, interaction duration and designation of the nurse. Trust is considered crucial in a mental health setting owing to the fact that presence of higher amount of trust in mental health profession by individuals with mental disorders, result in an increase in the likelihood of accessing and adhering to mental health services (Valente, 2017). Conversely, a lack of trust on the nurses increases disengagement of the clients from the care service. Nurses are expected to recognise the inherent worth, dignity and uniqueness of the clients that enable them to deliver effective pharmacological or non-pharmacological interventions in relation to the preferences and demands of the client. However, some major threats to the dignity of mentally ill patients include violation of human rights, discrimination and stigma (Gunasekara, Pentland, Rodgers & Patterson, 2014). Vulnerability of the patients create a power differential in their relationship with nurses.

Professional intimacy is also related to the inherent care that the nurses are expected to provide. Intimacy usually denotes presence of openness, mutual vulnerability, and sharing. However, some people suffering from severe mental disorders often require help in some activities of daily living such as bathing and dressing. Nurses are required to maintain dignity and privacy of their clients, while developing a closeness, with the aim of providing help (Hattingh et al., 2015). Furthermore, they are also expected to understand, validate and resonate with the mental distress that their clients currently suffer from. Appropriate use of power nurses to develop a partnership with their client, in accordance to their needs. Misuse of power often leads to abuse.

The Nurse-Client Relationship and Professional Boundaries

Some of the legal aspects of mental health nursing are governed by the standards that focuses on the professional development and ethical practice responsibilities of mental health nurses. In the delivery of care services and treatment, nursing practitioners are answerable to the clients, carers, and families, within their boundaries that are prescribed by the professional, national, and legal codes of conduct and practice (Ehrlich, Kendall, Frey, Kisely, Crowe & Crompton, 2014). They are expected to demonstrated sound legal decision making skills that are kept open for the scrutinisation of individuals with lived experiences of mental illnesses, colleagues and peers. The standards of practice also make the mental health nurses reflect on and incorporate mutual law requirements, pertinent statutes and their code of conduct (NMBA, 2010). Promoting and protecting the legal and human rights of the clients that commonly encompass the rights to refuse any treatment that is considered harmful or futile by the patient is essential. Moreover, nurses are also expected to take full informed consent of the patients, prior to administration of any intervention or care plan. No patients are allowed to be given any psychological or psychiatric treatment against will and should not be denied of the personal liberty, on grounds of mental illness. Thus, mental health nurses are held accountable to their practice according to the standards and laws (Ådnøy Eriksen, Arman, Davidson, Sundfør & Karlsson, 2014).

The nurses might use restraint and seclusion legally in emergent situations, for the least time possible, when it is considered utmost necessary for protecting their clients or others from forthcoming harm. Such emergency needs are supported by objective documentations. Mental health nurses are also responsible for uphold the standards, with the aim of ensuring that restraint and seclusion are not used in the form of punishment, threats, and/or staff convenience (Commonwealth of Australia, 2010). Nurses also have the duty of safeguarding confidentiality of the patient by discussing about matters related to patient care in private areas, which in turn is facilitated by the protection of medical records, proper disposal of discarded patient documents, and preventing publishing of pertinent patient information in social media (Humanrights.gov.au, 2018). Privileged communication is another right that mentally ill patients enjoy, which helps in protecting their information from being disseminated in some court of law. Legal competency to stand a particular trial, within criminal justice system is grounded on the ability of the defendant to comprehend the legal charges that are made.

Legal, Ethical and Professional Aspects of Professional Boundaries

This is in accordance to Victoria's Mental Health Act 2014 that puts person with mental illness at the middle of clinical decision making regarding their care and treatment (Mental Health Act, 2014). The Mental Health Act also encourages mental health nurses to improve relationships with individuals using services, and to deliver them with support and evidence to make conversant choices about care services. Depending on the condition of the patient, involuntary commitment are also pursued by mental health nurses on an emergency and indeterminate basis (Department of Health, 2013). Emergency commitment males the nurses hospitalise the patients who pose imminent danger and generally begins with filing of a petition by them or the family members. Extended or indeterminate commitment provides the scope of continuing care for mentally ill people. Owing to the fact that it lasts from 60-180 days, a judicial hearing is required for determining if the severity of the mental illness warrants it.

Mental health nursing is a sector within the health care sectors where the impact of ethical issues is extremely high. The ethical conflicts that mainly affect the psychiatric health care sectors is mostly in the community and inpatient setting. However, the most common ethical or moral issues that are faced by the mental health nurses in the Australian practice setting include beneficence, autonomy, nonmaleficence and confidentiality (Smith & Herber, 2015). According to the ethical principles of nursing, a nurse providing care to the patients will have to engage in activities that are beneficial to the health and welfare of the patients in order to maintain beneficence. Along with that, autonomy which entails prioritizing patient’s preferences over anything else and non-maleficence which requires a mental health nurse to refrain from engaging in any activities that has the slightest potential to harm the patient is important ethical requirement for the mental health nurses (Norvoll et al., 2017).

On a more exploratory note, these three ethical aspects receive the most of ethical dilemma among the mental health nurses, it has to be mentioned that for the mental patients, the addressing nurses often have to engage in interventions that can violate the broad aspects of beneficence or autonomy. Most importantly, the aspect of autonomy is subjected to most of the dilemma in the mental health with respect to beneficence and non-maleficence (Pelto-Piri, 2015). For example, a mental patient adamantly refusing treatment or therapeutic intervention will require the mental health nurse to somehow convince the patient against his or her wishes so that the patient can attain the treatment which will benefit him or her. However, these actions, even though acknowledge the need for the mental health nurse to follow the beneficence and nonmaleficence, but end up violating the ethical principles of autonomy. However, the use of restrains or any means of forcing is a strong violation of the ethical principle of nonmaleficence and is also considered breach of the professional boundaries of the mental health nursing practice scope and is strictly abhorred in practice as well.

Standards of Practice for Mental Health Nursing

However, maintaining client confidentiality is an extremely important professional requirement of a mental health nurse and any breach of confidentiality is considered as a direct violation of value statement 7 of ethical code of conduct for the nurses practicing in Australia (Voskes, 2015). With respect to the ethical code of conduct under NMBA, the value statement 5 of the code of ethics state that the nurses are expected to value the ethical decision making of the patients under any circumstances (Nursingmidwiferyboard.gov.au, 2018). In case of mental health patients, informing the patents prior to implementation of any intervention is considered a strict breach of the professional boundaries. However, for severely mentally ill patients, the perception of treatment and its value is often altered to a large extent which can lead to the patient refusing to participate in a treatment can be a very restrictive ethical dilemma for the mental health nurses. Often, the mental health nurses have to face the dilemma of decision making when considering the patient preferences without any clear understanding whether the patient is coherently refusing the treatment under cultural restrictions or not. In these cases, the patients have legal rights to refuse the treatment, the nurses will need to understand the patient cultural values and attempt to convince the patient ethically to agree to treatments without violating the professional boundaries to avoid the dilemma (Nursingmidwiferyboard.gov.au, 2018). Hence, the mental health nurses are subjected to face a varied range of different ethical dilemmas in everyday practice while providing care to the mentally ill patients, however, the professional standards and ethical code of conduct serves as key frameworks guiding the mental health nurse workforce to engage in as ethically congruent practice.

Thus, it can be concluded that one of the important lessons that all mental health nurses should identify early in their career include a sound understanding of their professional boundaries that make them define a relationship that assists formation of a therapeutic association with their clients. Therefore, mental health nurses should treat all patients with respect and dignity, inspire confidence in them, provide motivation, display fairness and advocate for the rights of the patient. In other words, a zone of helpfulness separates the therapeutic behaviour of mental health nurses from those that reduce the value of care to the mentally ill patients, their families and communities.

References

Ådnøy Eriksen, K., Arman, M., Davidson, L., Sundfør, B., & Karlsson, B. (2014). Challenges in relating to mental health professionals: Perspectives of persons with severe mental illness. International Journal of Mental Health Nursing, 23(2), 110-117. https://doi.org/10.1111/inm.12024

Campbell, R. J., Yonge, O., & Austin, W. (2016). Intimacy boundaries: Between mental health nurses & psychiatric patients. Journal of psychosocial nursing and mental health services, 43(5), 32-39. https://doi.org/10.3928/02793695-20050501-05

Commonwealth of Australia. (2010). National Standards for Mental Health Services. Retrieved from https://www.health.gov.au/internet/main/publishing.nsf/content/CFA833CB8C1AA178CA257BF0001E7520/$File/servst10v2.pdf.

Department of Health. (2013). National practice standards for the mental health workforce. Retrieved from https://www.health.gov.au/internet/main/publishing.nsf/content/5D7909E82304E6D2CA257C430004E877/$File/wkstd13.pdf.

Ehrlich, C., Kendall, E., Frey, N., Kisely, S., Crowe, E., & Crompton, D. (2014). Improving the physical health of people with severe mental illness: Boundaries of care provision. International Journal of Mental Health Nursing, 23(3), 243-251. https://doi.org/10.1111/inm.12050

Gunasekara, I., Pentland, T., Rodgers, T., & Patterson, S. (2014). What makes an excellent mental health nurse? A pragmatic inquiry initiated and conducted by people with lived experience of service use. International Journal of Mental Health Nursing, 23(2), 101-109. https://doi.org/10.1111/inm.12027

Hattingh, H. L., Knox, K., Fejzic, J., McConnell, D., Fowler, J. L., Mey, A., ... & Wheeler, A. J. (2015). Privacy and confidentiality: perspectives of mental health consumers and carers in pharmacy settings. International Journal of Pharmacy Practice, 23(1), 52-60. https://doi.org/10.1111/ijpp.12114

Humanrights.gov.au. (2018). Mental Health Legislation and Human Rights. Retrieved from https://www.humanrights.gov.au/our-work/disability-rights/publications/mental-health-legislation-and-human-rights.

Langendyk, V., Hegazi, I., Cowin, L., Johnson, M., & Wilson, I. (2015). Imagining alternative professional identities: Reconfiguring professional boundaries between nursing students and medical students. Academic Medicine, 90(6), 732-737. doi: 10.1097/ACM.0000000000000714

Mental Health Act. (2014). Retrieved from https://www2.health.vic.gov.au/mental-health/practice-and-service-quality/mental-health-act-2014

Niezen, M. G., & Mathijssen, J. J. (2014). Reframing professional boundaries in healthcare: a systematic review of facilitators and barriers to task reallocation from the domain of medicine to the nursing domain. Health Policy, 117(2), 151-169. https://doi.org/10.1016/j.healthpol.2014.04.016

Norvoll, R., Hem, M. H., & Pedersen, R. (2017, March). The role of ethics in reducing and improving the quality of coercion in mental health care. In HEC forum (Vol. 29, No. 1, pp. 59-74). Springer Netherlands. Retrieved from https://dare.ubvu.vu.nl/bitstream/handle/1871/52197/table?sequence=5

Nursing and Midwifery Board of Australia - Professional standards. (2018). Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Nursing and midwifery board of Australia. (2010). A nurse’s guide to professional boundaries. Retrieved from https://ahpra-search.clients.funnelback.com/s/redirect?collection=ahpra-websites- https://ahpra-search.clients.funnelback.com/s/cache?collection=ahpra-websites-web&doc=funnelback-web-crawl.warc&off=78786879&len=9787&url=http%3A%2F%2Fwww.nursingmidwiferyboard.gov.au%2Fdocuments%2Fdefault.aspx%3Frecord%3DWD10%252f1347%26dbid%3DAP%26chksum%3Dbes7sYtZAWnmggO%252fzV0uBQ%253d%253d&profile=nursingmidwifery&hl=(%3Fi)%5Cbprofessionals%5Cb%7C%5Cbprofessional%5Cb%7C%5Cbboundaries%5Cb%7C%5Cbboundary%5Cb

Pelto-Piri, V. (2015). Ethical considerations in psychiatric inpatient care: The ethical landscape in everyday practice as described by staff (Doctoral dissertation, Örebro university). Retrieved from https://www.diva-portal.org/smash/record.jsf?pid=diva2%3A792455&dswid=-5528

Smith, J. P., & Herber, O. R. (2015). Ethical issues experienced by mental health nurses in the administration of antipsychotic depot and long?acting intramuscular injections: A qualitative study. International journal of mental health nursing, 24(3), 222-230. Doi: 10.1111/inm.12105

Valente, S. M. (2017). Managing professional and nurse–patient relationship boundaries in mental health. Journal of psychosocial nursing and mental health services, 55(1), 45-51. https://doi.org/10.3928/02793695-20170119-09

Voskes, Y. (2015). No effect without ethics: Reduction of seclusion in psychiatry from a care ethics perspective. Doi: 10.1007/s10730-016-9312-1