Treatment Boundaries for Psychiatric Nurses: Conflict Resolution

Introduction

The nursing profession is perhaps one of the most dynamic and complex, as it is very difficult to draw clear lines of duty. Almost all patients challenge nurses to care for them, and yet many see them as either adversaries or allies (Martin Teising, 1997). This is particularly true for certified psychiatric nurse assistants, because defining the boundaries of duty for psychiatric nurses has become extremely difficult. Theorists, practitioners, and physicians alike have not only proposed numerous work boundaries for nurses, but have also instructed them to carry out multidisciplinary tasks.

Some suggest that the psychiatric nurse should offer recognition and sympathy and assist the patient in expressing feelings; some suggest that they should assist the patient in communicating; others suggest that they should help patients contribute socially within the healthcare setting; some believe nurses should make the patient conscious of his or her own actions and how those actions influence other patients; some suggest that nurses should assist the patient in understanding his or her own mindset relative to the total situation in which he or she finds themselves; and still others say that nurses should discuss alternative behaviors to help the patient work through personal difficulties (Suzanne Lego, 1999).

In light of the above, it is important to draw clear lines of duty for psychiatric nurses so that this discrepancy can end and nurses can focus on their everyday responsibilities rather than being drawn into matters outside their professional scope. This paper provides an in-depth review of the problem of nurses' treatment boundaries and applies conflict resolution techniques to address the conflict.

An In-Depth Review of the Problem

Many theorists, practitioners, and physicians have underestimated the importance of defining work boundaries for psychiatric nurses. This is because they tend to regard nurses as somewhat inferior in status and assume that their responsibilities can be shifted at will. While numerous scholars have pointed out discrimination against the nursing profession, very few have actually assessed the implications of manipulating the work boundaries of psychiatric nurses. This subject is important not only for nurses themselves but also for the healthcare industry as a whole, since psychiatric nurses form the backbone of hospital services. By allowing them to drift away from their assigned tasks, hospitals risk failing to provide quality care.

As noted above, very few scholars have studied the impact of failing to define work boundaries for nurses. However, Cindy A. Peternelj-Taylor and Olive Yonge (2003) provide an in-depth examination of this subject. They write: "The ability to create and maintain treatment boundaries within the nurse-client relationship is one of the most important competencies required by psychiatric-mental health nurses. However simple this declaration, in practice, boundary work is anything but straightforward. The familiarity and trust that develop between a nurse and a client, coupled with the seductive pull of helping, the complexity of the client's treatment needs, and a general lack of understanding of boundary theory, can threaten the integrity of the relationship and ultimately lead to boundary violations. Ironically, through engaging a client in a professional caring relationship — the essence of psychiatric-mental health nursing — nurses are at risk of overstepping their professional boundaries" (Peternelj-Taylor & Yonge, 2003).

In the twenty-first century, psychiatric nurses may find themselves in a wide variety of workplace settings. Peternelj-Taylor and Yonge (2003) write: "Contemporary psychiatric-mental health nurses practice in a multitude of settings and embrace a variety of therapeutic roles. They may find themselves working autonomously in independent practice or collaboratively as members of interdisciplinary teams. They may be employees of the healthcare system and practice in traditional community- and hospital-based settings, or they may find themselves working within the criminal justice system, in a variety of secure environments such as prisons and forensic psychiatric units. Although the issues dealt with in practice may on the surface appear to be quite significant, in reality a clearly defined distinction is nonexistent. It is the therapeutic nurse-client relationship that is the foundation of psychiatric-mental health nursing, one that unites psychiatric-mental health nurses regardless of the settings in which they practice" (Peternelj-Taylor & Yonge, 2003).

It is clear that defining treatment boundaries within the nurse-client relationship has become extremely important, both for nurses individually and for the healthcare system generally. Many nurses have turned to psychology, medicine, and social work for guidance in understanding their working boundaries. While this approach has helped define a broad treatment boundary for nurses, proper strategies must still be applied to resolve this conflict. As Peternelj-Taylor and Yonge (2003) write: "Nurses frequently work in situations where the boundaries of the nurse-client relationship are tested, either by their own actions or through the actions of their clients. Their response to these 'tests' is a matter of professional integrity, and nurses, by virtue of the power inherent in their professional role, are expected to do the right thing, even when it is not always clear what 'doing the right thing' might look like."

Strategies and Tactics for Conflict Resolution

They further write: "Through this discourse, nurse therapists will be faced with examining many of the hazards that have the potential to threaten the integrity of the therapeutic relationship. As a result, they will be challenged to reflect on the meaning of professional boundaries in their relationships with clients and, ultimately, they will be better positioned to navigate the slippery slope of the therapeutic relationship and work with clients in a competent and ethical manner" (Peternelj-Taylor & Yonge, 2003).

Self-Consciousness and Self-Screening

Many theorists have downplayed the importance of self-understanding and self-recognition. They believe that self-awareness and acknowledgment of boundary abuse will not resolve problems for certified psychiatric nurse assistants and that effective strategies must be developed that focus on client behavior instead. However, Peternelj-Taylor and Yonge (2003) write: "Prevention of boundary violations in the nurse-client relationship requires open acknowledgment that the potential for abuse exists in all therapeutic relationships. However, professionals are often quick to separate those who violate boundaries from themselves by embracing what Gabbard has referred to as an 'us/them' scenario. In doing so, professionals delude themselves into thinking that boundary transgressions can only happen to others who might be described as 'addicted,' 'lovesick,' 'psychopathic,' or 'narcissistic,' leaving few opportunities for personal reflection and exploration of their own vulnerabilities" (Peternelj-Taylor & Yonge, 2003).

The self-consciousness and self-screening strategy allows certified psychiatric nurse assistants to prevent crossing treatment boundaries. Peternelj-Taylor and Yonge (2003) write: "As a personal risk-management strategy, self-awareness can assist therapists in appropriately managing treatment boundaries, by acknowledging boundary crossings and thereby avoiding the stepwise progression of boundary violations. In recent years a variety of self-assessment inventories have been developed that can be used to further nurses' (and other healthcare professionals') comprehension of treatment boundaries."