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Can healthcare staff have too many professional boundaries?

Esther Flanagan 13 January 2016

In this blog Esther Flanagan, Schwartz Rounds programme manager and clinical psychologist, explores the current culture of staff and patient relationships and its limitations using some of her own patient experiences.

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Healthcare staff learn and are expected to execute their work using a ‘professional’ approach. But in the context of striving to humanise healthcare, can professionalism be restrictive? I am particularly interested in whether boundaries between staff and patients can inhibit care if too much emphasis is placed on professionalism and not enough attention is paid to the personal.

The HCPC says that “any absolute approach to defining what is or is not professional will be problematic”, given the infinite number of professional interactions that take place on a daily basis.

So, professionalism isn’t uniform; it is a dynamic concept that changes with each staff-patient interaction. Therefore, staff need to pay careful attention in order to manage the boundaries between their personal and professional selves.

Creating a safe distance

These boundaries exist in order to protect the patient as well as the professional.  The caregiver is entrusted with the responsibility to keep their patient safe. When you consider cases of professional misconduct, such as the recent case of psychologist Dr Winter, the value of that safety becomes clear.

We know from patient accounts that some of the most valued aspects of care are moments when staff members have connected with patients on a human level. But in order to connect, do staff need to relax their professional boundaries, for example by showing some vulnerability or authentic emotion? How easy is that to achieve without compromising professional credibility? Are there different expectations of boundaries across disciplines? For example, would we expect a nurse to put up fewer boundaries than a doctor? The balance between the personal and professional is a topic that is discussed regularly at Schwartz Rounds, and one that I have also considered in my own clinical work.

Unbalanced relationships

When training as a clinical psychologist I remember feeling apprehensive as we were taught explicitly not to reveal personal details about ourselves. So when patients occasionally asked questions about my personal life I would feel my stomach lurch a little. I made sure to reveal minimal information, sometimes using stock phrases such as ‘this is your space, so let’s make sure we use it to focus on you’. I never really felt comfortable responding in this way, but my intention was to uphold ‘professionalism’.

The most challenging (and often comical) experience I had managing boundaries was with an inquisitive young boy with a learning disability. After I had attempted to explain the nature of professional relationships, he proceeded (for many weeks) to end any question he had with, ‘is that too personal?’ It highlighted to me the one-sidedness of the staff-patient interaction. I think that I ended up disclosing more to him than any other patient, e.g. what food I ate and what music I liked, which I came to see largely as innocuous and necessary for the therapeutic relationship.

I feel increasingly that connecting on a human level with patients (even if that means sharing a small part of yourself) is crucial to developing a genuine therapeutic relationship. Some may see that as unprofessional, but others may see it as a necessity for patients to relate to staff as fellow human beings. The boundaries that are established will of course depend on the patient’s needs and expectations, the type of clinical interaction and the context of the service.

Containing emotional exposure

A fundamental part of managing professional boundaries is the ability to contain emotion, which often requires the clinician to withhold their real emotional response. For example, I have held back from showing feelings of anger or disgust when people tell me they have been abused, or sadness when people describe their loss, instead carefully choosing when and if to share my own emotional reaction. But could some patients benefit from seeing an immediate and genuine response? How much emotion is too much and how much is too little?

I was struck by the story of BBC newsreader Graham Satchell who broke down during a report about the Paris terror attack. I believe this attracted support from the public because viewers saw the person behind the professional. Graham’s reaction was unusual and unexpected, but it normalised their own emotional reaction to the event, highlighting an appreciation for authenticity.

A balancing act

Many healthcare professionals attest that their most memorable and powerful experiences have been when they have shared pain or joy with a patient, so is it right that this kind of connection is seen as the exception, not the rule? The general consensus seems to be that some level of disclosure or sharing of emotion is helpful, but only when it is in the service of the patient.

As with many aspects of healthcare work, staff are negotiating a careful balance between their personal and professional selves, which isn’t always easy to achieve.