Chapter 8: Boundary Issues
The Concept of Boundaries
Think of boundaries as lines that we do not cross. We’re all familiar with these lines; we start encountering them as very young children, and knowledge of where they lie comes from socialization—learning how to live in our culture. For example, as a student you can bring personal belongings, sports equipment, and maybe even your car to school, but if you bring a weapon, you’ve crossed a line. It’s okay to write an opinionated blog or spend all your free time playing video games, but if you stalk someone on the internet, you’ve crossed a line. These are boundaries, and they exist in both our personal and professional lives.
This handbook is all about boundaries, and where they lie for the licensed MLT in Nova Scotia. Many of our professional boundaries are obvious, and they can be described from different perspectives. A boundary crossing might be, for instance:
- A violation of trust, such as a breach of patient confidentiality, working while impaired by drugs or alcohol, or falsifying test results
- Abuse of power, such as ordering and performing tests on yourself or family members, or using your professional status to steer patients toward a private clinic owned by a friend
- Conflict of interest, where you do something that benefits you, rather than benefiting patients/clients
Failure to respect professional boundaries, whether deliberate or due to a lack of understanding, can not only lead to serious consequences for you, it can damage the public image of our entire profession.
Why Boundary Crossings Occur
If you’re a seasoned MLT, you may recognize some familiar scenarios in this chapter, and possibly even think to yourself “I’ve done that!” It’s true that boundary crossings occur quite frequently. Why? Even the most well- meaning person may cross a boundary because they:
- Believe it is a minor, harmless action and/or no one will notice
- Think it’s okay because others do it
- Rationalize that the ends justify the means
- Don’t want to refuse a request from a friend or relative
- Succumb to temptation and/or poor judgment
- Let an innocent situation slide gradually into one that is inappropriate
SCENARIO:
Your mother’s dog has a thyroid problem and has to have blood tests for thyroid function every six months. The cost really adds up once mom has paid for the veterinary visit and the cost of the test, and she’s living on a fixed income. You work in clinical chemistry and you know you can get the technologist doing the test to slip the dog’s sample into a patient batch as a proficiency specimen. Who will care about one little blood test twice a year? You tell your mom that if she can get the blood sample, you’ll get her the results for free.
This is a seductive scenario because the boundary crossing, though clear, seems very minor. The veterinarian, your mother, and your co-workers all clearly think it’s okay, you get to help out your mom, and the dog gets good care. It’s a win-win-win, except that you are stealing employer resources— time and materials—to do it. You are also, presumably, falsifying proficiency documents for the chemistry lab. This is a line you should not cross.
Medical laboratory technologists have little direct patient contact, and even little direct contact with other health care professionals. We typically work behind closed doors, sometimes even alone, and can expect a certain amount of indulgence from our close co-workers. Even fairly major lapses can go unnoticed and/or unreported. Because of this, we are at particular risk of crossing some boundaries, and it requires tremendous integrity and self respect to avoid that.
Today, professionalism is as important as it has ever been. Increased scrutiny, accreditation, higher risk of malpractice suits, and the excellence expected of licensed health care professionals all mean that we must hold ourselves to the highest possible standard. It’s your responsibility to know where your professional boundaries lie, and respect them. As discussed under conflicts of interest, when deciding on whether any particular action constitutes a boundary crossing, it is helpful to ask yourself whether you’d be comfortable telling others about it. If not, you are likely crossing the line.
Two important types of boundary crossing include breaches of confidentiality and conflict of interest. These are discussed in previous chapters of this handbook (4 and 7, respectively). There are other types of boundary crossing that the MLT must be sensitive to.
Sexual Abuse and Boundaries
The issue of sexual abuse can arise in any relationship where there is an obvious or potential imbalance of power. For many health care professionals, the major concern is the relationship between the professional and the patient, and this applies to us as well; however, we have more prevalent relationships where boundaries related to sexual abuse are important:
- While teaching, or guiding students or visitors in the lab
- While supervising lab assistants or other lab staff
- With new employees or anyone subordinate to you
- With co-workers in general (jokes and remarks of a sexual nature)
An imbalance of power isn’t necessarily easy to recognize. Individuals may be equals in terms of their job description and experience; however, any situation where one person feels vulnerable or helpless at the hands of another is an imbalance of power. For example, a co-worker might get away with an inappropriate and lewd joke that makes you uncomfortable because both of you know others will judge you negatively if you complain about it. This is bullying, and it is sexual abuse.
SCENARIO:
Joann, an MLT responsible for teaching students in the lab, and Ibrahim, a student from the community college, discover that they have lots of mutual interests, and start seeing each other outside of work hours. The attraction is mutual, their relationship develops quickly, and even though they try to keep it quiet, other technologists in the lab can’t help but notice. Is this sexual abuse?
Neither Joann nor Ibrahim are likely to identify their relationship as sexual abuse because they have both entered into the relationship freely, and are consenting adults. There is, however, a clear imbalance of power between them: Ibrahim is doing a rotation in the lab, which he needs to complete his course and qualify as a registered technologist; Joann is in a position to show him favoritism, or make his life difficult and his assessment poor. She has power over him. As long as he’s a student under her supervision, her relationship with him constitutes sexual abuse. There may, in fact, be a policy in place in the workplace forbidding this type of relationship.
Fortunately for Joann and Ibrahim, this situation can probably be resolved relatively easily. They need to acknowledge the problem and either agree to set their personal feelings each other aside until Ibrahim’s rotation in the lab is over or, even better, ask whether another technologist can be assigned to look after Ibrahim for the remainder of the rotation. Once Joann is no longer in a position of power over Ibrahim, they are free to pursue their relationship.
Not all instances of potential sexual abuse are this easy to resolve. And like this one, many are not immediately obvious. In order to avoid being guilty of sexual abuse, or even appearing guilty, remember the following:
- Be aware of and follow workplace policies regarding sexual abuse.
- Don’t initiate unnecessary physical contact. Even innocently resting a hand on someone’s shoulder can be misinterpreted.
- Avoid being alone with others who are vulnerable. Leave doors open and if it feels uncomfortable, acknowledge the problem. Get help or change locations if possible.
- Don’t get personally involved with those you have power over. Avoid discussion of personal lives and problems.
- Be open and straightforward about situations that lend themselves to the possibility of sexual abuse.
- Keep your conversation professional.
- Deal with boundary crossings by others promptly.
- Report sexual abuse if you observe it.
Direct Patient Contact — Special Considerations
Medical laboratory technologists who deal directly with patients must always be cautious not to cross professional boundaries. Here, the balance of power is inherently uneven because of your status as a health care professional, and you typically have no way of knowing if a patient is sensitive or vulnerable because you are strangers to each other. Be careful to remain professional at all times.
In addition to avoiding breaches of confidentiality and conflicts of interest, follow the advice given above and:
- Always identify yourself, explain your purpose, and obtain informed consent before touching.
- Never place items such as blood tubes or specimen containers on a person’s body.
- Don’t disclose information about your personal life except in the most general terms.
- Don’t enter into social media “relationships” with patients.
- Avoid giving and receiving gifts.
- Resist the urge to offer help to someone who appears to be in particular need. Any interaction that goes beyond the requirements of your job is suspect, and risky.
- Don’t enter into dual relationships. Friendships and romantic relationships don’t mix with health care professional/client relationships.
Family Members and Friends
As health care professionals, MLTs not only have the ability to access personal health information, we can also perform tests in the lab at will by adding additional tests to requisitions or even filling out requisitions ourselves. It is often tempting to bypass the usual procedures to help someone close to us, as in the previous scenario of thyroid testing on the family dog. This temptation is multifaceted—by bending the rules you can potentially:
- Shorten the turn around time for a lab test by cutting out the visit to a physician, fast tracking the test, and/or obtaining a quick report
- Get test results that might otherwise be unavailable (or costly)
- Shorten someone’s illness and discomfort
- Avoid inconvenient trips to a doctor or emergency
- Set people’s minds at ease
- Set your own mind at ease
- Obtain information about people you know
This type of misconduct is probably the most common and seductive boundary crossing in our profession. It is typically easy to do, overlooked by others, and appreciated by friends and family who receive special attention. It is, however, unacceptable.
SCENARIO:
Brittany works in the anatomical pathology lab. Her father-in-law has surgery to remove a malignant tumor, and tissue is sent to the lab and processed as usual. By chance, Brittany is within hearing distance when the pathologist dictates the results, and learns that the “margins are clear.” The malignancy has been completely removed.
Hours later, family members still have not received the news that the surgeon got the whole tumor and Brittany is tempted to ease their anxiety by disclosing what she’s heard, but she does not do so. Later, her mother-in-law realizes that Brittany knew, and she’s extremely angry that Brittany withheld the information. Would it have been okay for Brittany to disclose the pathology result?
Although Brittany didn’t deliberately position herself to hear the results of the pathology specimen, she’s arguably guilty of a breach of confidentiality in knowing them. If she knew the pathologist was reading her father-in- law’s slides, she should have moved out of earshot, or, if that was impossible, she should have alerted the pathologist to the situation. Aside from being the professional thing to do, this would have saved her considerable angst later on.
Brittany was right, however, in keeping the results to herself, despite the personal cost. To disclose those results would be practising outside her scope of practice: MLTs do not diagnose, and do not provide test results directly to patients or family members. It would also be a breach of confidentiality in that she might provide information to family members who don’t have the right to it. Finally, we must consider that she didn’t necessarily have access to the whole picture – there might be other specimens, other tests, or other considerations unknown to her, that would affect the information the surgeon shared.
Ordering or performing tests that have not been ordered by a physician (or in the case of an animal, a veterinarian) is practising outside your professional scope of practice. The same applies to disclosing results directly to the patient or anyone close to the patient. It is also potentially stealing if you are using employer resources and time without permission and/or potential for reimbursement.
Similarly, looking up someone’s test results is a breach of privacy. Printing reports risks an even bigger breach of privacy because those pieces of paper might fall into other hands.
All of these activities constitute professional misconduct and can result in severe consequences.
Ignoring Established Conventions
“That’s the way it’s always been done” is not generally a good reason for resisting change; however, it’s a good point to keep in mind when being careful to stay within your professional boundaries. If there’s an established way of doing something in your workplace, and you decide to do it differently, consider what your motives are and how your actions will appear to others. You might change your mind, or take some precautionary measures to ensure that you don’t cross any lines. Whatever you do, be sure it complies with policies in your workplace.
SCENARIO:
It’s “Take Our Kids to Work Day” in the hematology lab and Brad has been assigned to give the “kids” the grand tour. This year, there are two participants, and both are attractive flirtatious grade-nine girls.
In previous years, the technologist assigned to the students has taken them through the different areas of the lab, with commentary and some interaction with technologists working on various benches. Brad decides that he can lessen work interruption and decrease the problem of background noise if he gives the girls a general introduction to the lab first, and has a question and answer period. He takes them off into a secluded empty office and closes the door. Initial amusement on the part of other staff turns to genuine concern when the office door remains closed after a considerable time. Has Brad crossed a line?
One of the biggest problems in this scenario is that we will never know for sure if Brad crossed a line. Taking the girls into a private and secluded room and closing the door raises all kinds of problems:
- There is an appearance of possible misconduct.
- The girls might feel uncomfortable and unsafe.
- Brad might be tempted to make inappropriate advances.
- Brad is leaving himself open to false accusations.
Brad should have thought twice before placing both himself and the girls in such a vulnerable position. Sticking to the usual plan would likely have been the best course of action. Was work interruption and noise level really the reason he made this decision? It’s possible even he doesn’t know. If Brad really felt it was necessary to take the girls aside, it would have been much better to choose a more public space, and leave the door open.
Boundaries Also Protect the Medical Laboratory Technologist
The “Take Our Kids to Work Day” scenario in the previous section highlights an important point: boundaries exist to protect us as well. The grade nine girls weren’t the only ones that were vulnerable in that situation. Brad was vulnerable too.
Just as you need to respect professional boundaries, you will sometimes need to draw the line for others in order to protect yourself from abuse or professional misconduct, or even the appearance of professional misconduct. Potential examples include:
- Unwelcome or inappropriate advances of a sexual nature
- Sexual, verbal or physical abuse, or bullying
- Unauthorized requests for someone’s personal health information
- Requests for sample testing or test results through improper channels
- Inappropriate requests for connections through social media
In each of these cases, politely explain why the other person’s behavior is inappropriate, if it’s safe to do so, and establish where the boundary lies. If this doesn’t resolve the issue, report the problem and get some help. (Depending on the seriousness of the incident, it may be necessary to report the problem in any case.) Document the incident.
If you respect boundaries, and request that others respect them as well, you are greatly decreasing the chance that you will suffer personal harm, or be accused of professional misconduct as a result of a boundary crossing.
Conclusion
Boundaries exist to prevent people from harming one another. Because harm can come in many forms—physical, emotional, financial, social, professional etc.—the variety of boundary crossings can seem endless. Nonetheless, we tend to have a good sense of where the boundaries lie: if it feels wrong it probably is wrong.
Medical laboratory technologists use employer policy, professional ethics, and good judgment to identify boundaries for ourselves and the people we interact with. We do this not only to protect others from harm, but to protect ourselves as well.
