I wanted to say to the professional “what are you doing? This is not right”, but my limited knowledge and experience won the better of me, and I opted in stead just to observe and internalize the situation.
FEELINGS
Consequently, the results for me were that I was tormented by my conscience, because deep down inside I knew that there was a potential problem which I was not addressing, and that there was a need to take advice from someone in authority to myself. I felt fearful of the repercussions of reporting the incident, so I tried to use a utilitarian approach to convince myself that by ignoring the incident and making the majority of people happy, that this problem would go away. (Tschudin 1994)
Nevertheless, as a result of my conscience, I decided to briefly mention the incident to a registered nurse, who appeared quite concerned by my findings. She offered me rational advice, but did not appear to point me in the right direction I felt that this advice was not appropriate in respect of the incident. My next step should have been to get more support from my mentor but I did not. I now feel annoyed with myself, because I was then left with the uncertainty of not knowing for definite whether what I had witnessed was right or wrong. I was also now feeling rather apprehensive about my nursing interventions with Carol, knowing that someone else had crossed the boundaries of professionalism with her. I wanted to be able to offer Carol the therapeutic care that she was eligible to.
EVALUATION - BAD POINTS
The more I tried to evaluate this incident, the worst it became in my mind. There did not appear to be much good in a professional to client relationship like the one which I had witnessed. The care given by the professional should have been based on therapeutics. Therapeutic care by healthcare professionals should focus solely on the client (Lyttle & Mathias 2000). Therefore, even though the profession of Carols support worker was not from the nursing field, I think that she would still have been governed by a professional body that administered guidelines for the care of the vulnerable adult.
Thinking about Carol, it is rather difficult to know how she felt about the incident, I can only presume that this was the normal behavior expected by her from this carer. On this occasion she responded in what appeared a positive way, and was only to pleased to oblige. I was not however sure that Carol was fully aware of the implications of her response, as she had mental health problems, which made it questionable as to how she may have perceived the request.
GOOD POINTS
At first, I could not see any good points in this situation itself, however, looking back I can see that it did have its positive side, in as much as allowing me to examine myself and to search for my short fallings in relation to the incident. I feel that if I was not a 1st year student, I would have had more knowledge or communication skills on how to deal with an incident of this description, I also think that because the support worker was not a nurse, it made it more difficult for me to make a decision on what the correct procedure should have been.
On further evaluation of this incident, I can see how my first tutorial on module DN2 in relation to professional ethics and a ‘trigger’ relate to this incident. I did not feel good or comfortable with this situation, therefore this was the right time to question why it did not feel right.
ANALYSIS
I still wonder why the support worker instigated such a response from Carol, and I blame my lack of knowledge in relation to professional issues as my reason for not reacting more assertively at the time of the incident. Without adequate knowledge it is relatively difficult to know how to handle the nurse-client relationship, as knowledge is a first and an important precondition for meaningful ethical reflection in situations in which morally good action is desired. ( Nursing Ethics 1998) As a student nurse, my first thoughts should have been of my professionalism and of the clients wellbeing, because although this carer was professional she was not a nurse. The Code of Professional Conduct (2002) clearly states that nurses should “promote and safeguard the interest of the patients”, and because I am governed by this professional body, I could have been held accountable for the actions of this carer had any further incidents evolved from the one which I witnessed, because I am personally accountable for my own practice, and in the duty of my professional accountability, I must make sure that I avoid any abuse of my relationship with clients (Code of Professional Conduct 2002).
As professionals, it is important that good and no harm comes to the clients by whatever means. Bloch and Chodoff (1999) define the term for this as non-maleficence. To encourage a client into an intimate action as the one described, would then appear not to be promoting any good, as the repercussions of this act could have resulted in a serious matter, and could even be misconstrued as abuse, especially as the client is deemed as vulnerable. It was clear that Carol did not have the capacity to consent to sexual interactions, because as Rumbold (1999) states, in order to be considered to have the capacity to consent, a person must be capable of understanding what is being asked and also its implications. The client must be able to exercise choice and it is important to consider whether one party is in a position of power which will influence the ability of the other party to consent (Barker and Davidson 1998). The Practitioner Client Relationships (2002) states, that there are some groups of patients which are deemed more vulnerable than others, psychiatric patients are one of these groups. When clients are already deemed as vulnerable, control such as manipulation, which is irresistible, unwelcome or non-persuasive is ethically unjustifiable. Manipulation and deception are very similar, as both treat someone as a means to another persons ends and are a direct attack on the clients’ control over their own lives. Clients with mental health problems may not always have the perception to fully understand their situation, mainly because of their thought disorders , or sometimes it may be that they are suffering so much with anxiety that they can never make balanced choices, or reach levels of full autonomy. This does not mean that as professionals there is a right to disrespect an individual, or use this reason to justify an action. (Tschudin 1994).
As a professional, it important to ensure that the care provided to a client is done so in a manner which is free of abuse, sexual context or connotation. The relationship between a professional and client is built on trust, respect, compassion and honesty. (Stuart and Laraia 1998) Dexter and Wash (1997) reminds us that the clients’ trust rests on the assumption that the professional will operate within the context of the clients needs. When the client expects this and projects an aura of security in the professional, the client’s vulnerability becomes a key factor in the relationship. Therefore, between a professional and client, the balance of power is unequal and there then is an inherent potential for abuse. It is an abuse of clients trust and dependence on the professional and a betrayal of the trust imparted on the professional by society (Lyttle & Mathias 2000). This form of abuse often deeply violates clients and sometimes causes tremendous spiritual, emotional and psychological harm. The action described in the incident cannot therefore be considered consensual when there is a power imbalance. This power imbalance occurs because the professional has authority, knowledge, access to information and influence, but as Palmer (1994) states, we should be always aware of the power imbalance between ourselves and clients and ensure that our power is directed to meeting the needs of the clients only. There is only one way which this can be achieved, and that is by establishing professional boundaries.
Boundary violation is more of a process than a single event, it may take time before boundarys have been crossed. The dictionary definition of a boundary is ‘ to limit or restrict’ (Collins 2000 p.54). Few professionals according to Lott (1999 ) decide to take advantage of an individual. Yet when professionals deny or remain unaware of their personal power or authority, they will begin the process of boundary violation by misusing power. When a professional exploits a relationship to meet personal needs rather than the needs of the client, the boundaries have slipped and peril is on the horizon.
It is important as professionals to be forever aware of our potential to break boundaries with clients, we should therefore have the ability to set limits. Clients must be free to express their sexuality appropriately, but this must be balanced against the risk of abuse or exploitation, but boundaries must be set for the protection of both client and professional. The Code of Professional Practice (2002 ) reinforces in the guidelines, that this is clearly the responsibility of the professional, and that all areas of the relationships with patients must wholly be centred around the client and his needs.
A relationship, in particular a professional therapeutic relationship indicates that there must be a limit, because the consequences of undefining the therapeutic relationship may result in uncomfortable feelings, perhaps even to some degree psychological and interpersonal turmoil. Violations of professional boundaries move the relationship into non-therapeutic zones. (Berk and Achber 1995)
CONCLUSION
On reflection of this incident, I felt that the approach which I took was not quite correct. Being now more knowledgeable in relation to the therapeutic relationship of the client and professional, I know that there was not anything therapeutic about this incident. Following my own beliefs and values, I should have acted immediately, by obtaining advice from my mentor, without hesitation, making her aware of my concerns and should have acted as an advocate on behalf of the patient, who was deemed as vulnerable. I am aware that as a qualified nurse, I will be accountable for my own actions (Code of Professional Conduct 2002), so in relation to this incident, to ignore it, in the hope of it disappearing, would have been just as bad as being the perpetrator. (Chadwick and Tadd 1992)
I feel that it is important to constantly evaluate our professional boundaries with clients. In all professional relationships, there is more than likely a potential for conflicts of interest, because professionals will develop feelings for clients or clients families. This is only wrong when the professional acts on these feelings inappropriately, which I feel was the case in this incident. (Patient Client Relationships 2002).
I feel that I am now growing in knowledge, experience and confidence, and that I am becoming more aware of my own beliefs and values, and also how they affect my nursing experience, and those of others.
ACTION PLAN
In order to prevent another situation of this kind happening to me again, I feel that I must act on my own values and beliefs, being careful not to impose them on anyone else. I will do the ‘right’ thing at any given moment in any given situation, regardless of the consequences. I will not ignore the situation next time, hoping that it will just disappear, because I know now that I could be held accountable if any serious issue came to light from something which I chose not to report. I have also learned that I need to further my assertiveness and communication skills so that I do not feel intimidated or belittled when addressing these issues to members of staff in senior positions to myself. I have also learned that positive experiences can be gained through negative incidents, as this one made me realize that I need to further develop my skills in order to offer the appropriate care which each client is worthy of receiving.
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