Professional boundaries &

moral obligation
Learning Outcomes:

1. Explain the professional boundaries and moral

obligation in healthcare.
2. Relate concept of culture and provision of
culturally sensitive care.
3. Identify mechanism for enhancing clinical
practice, professional practices and
professional development.
Professional boundaries and moral obligation in healthcare

1. Sign of over-involvement
2. Under-involvement
3. Self-disclosure
Professional boundaries and moral obligation in healthcare

● A therapeutic relationship is one that allows health care

professional to apply their professional knowledge, skills, abilities
and experiences towards meeting the health needs of the patient.
● This relationship is dynamic, goal-oriented and patient- and
family-centered because it is designed to meet the needs of the
patient and family.
● Regardless of the context or length of interaction, the therapeutic
health care professional–patient relationship protects the
patient’s dignity, autonomy and privacy and allows for the
development of trust and respect.
Professional boundaries and moral obligation in healthcare

● Professional boundaries are the spaces between the health care

professional’s power and the patient’s vulnerability.
● The power of the health care professional comes from the
professional position and access to sensitive personal information.
● The difference in personal information the health care professional
knows about the patient versus personal information the patient
knows about the health care professional creates an imbalance in
the health care professional–patient relationship.
● Health care professional should make every effort to respect the
power imbalance and ensure a patient-centered relationship.
Professional boundaries and moral obligation in healthcare

● Boundary crossings are brief excursions across professional

lines of behavior that may be inadvertent, thoughtless or
even purposeful, while attempting to meet a special
therapeutic need of the patient.
● Boundary crossings can result in a return to established
boundaries, but should be evaluated by the health care
professional for potential adverse patient consequences
and implications.
● Repeated boundary crossings should be avoided.
Professional boundaries and moral obligation in healthcare

● Boundary violations can result when there is confusion

between the health care professional and those of the
patient.
● Such violations are characterized by excessive personal
disclosure by the health care professional, secrecy or even
a reversal of roles.
● Boundary violations can cause distress for the patient,
which may not be recognized or felt by the patient until
harmful consequences occur.
Professional boundaries and moral obligation in healthcare

● A health care professional’s use of social media is

another way that they can unintentionally blur the
lines between their professional and personal lives.
● Making a comment via social media, even if done on
a their own time and in their own home, regarding an
incident or person in the scope of their employment,
may be a breach of patient confidentiality or privacy,
as well as a boundary violation.
Professional boundaries and moral obligation in healthcare

This continuum provides a frame of reference to assist

health care professional in evaluating their own and their
colleagues’ professional–patient interactions.
Professional boundaries and moral obligation in healthcare

● Every health care professional–patient relationship

can be conceptualized on the continuum of
professional behavior.
● Health care professional can use this graphic as a
frame of reference to evaluate their behavior and
consider if they are acting within the confines of the
therapeutic relationship or if they are underinvloved
or overinvolved in their patients’ care.
Professional boundaries and moral obligation in healthcare

1. Overinvolvement includes boundary

crossings, boundary violations and
professional sexual misconduct.
2. Under involvement includes patient
abandonment, disinterest and neglect, and can
be detrimental to the patient and the health
care professional.
Professional boundaries and moral obligation in healthcare

● There are a number of areas in which one has to maintain boundaries,

that is, “draw a line”.
● Below are some typical areas that can present difficulties.
a. Self-disclosure
b. Giving or receiving significant gifts
c. Dual and overlapping relationships
d. Power Imbalances
e. Becoming friends
f. Dating
g. Maintaining established conventions
h. Physical Contact
i. Informal Communication and Humour
Professional boundaries and moral obligation in healthcare

● Self-disclosure
○ Although in some cases self-disclosure may be
appropriate, members need to be careful that the
purpose of the self-disclosure is for the client’s
benefit.
○ A number of dangers may exist in self disclosure
including shifting the focus from the needs of the
client to the needs of the clinician, moving the
professional relationship towards one of friendship.
Professional boundaries and moral obligation in healthcare

● Self-disclosure (cont.)
○ The blurring of boundaries may confuse
the client with respect to roles and
expectations.
○ The primary question to be asked is, “Does
the self-disclosure serve the client’s
clinical goals?”
Professional boundaries and moral obligation in healthcare

● Giving or receiving significant gifts

○ Giving or receiving gifts of more than token value
is contrary to professional standards because of
the risk of changing the clinical relationship.
○ For example, a client who receives a gift from a
member could feel pressured to reciprocate in
order to avoid damaging the relationship and
consequently receiving “inferior” care.
Professional boundaries and moral obligation in healthcare

● Giving or receiving significant gifts (cont.)

○ Conversely, a member who accepts a
significant gift from a client risks altering
the clinical relationship and could feel
pressured to reciprocate by offering
“special” care.
Professional boundaries and moral obligation in healthcare

● Dual and overlapping relationships

○ Dual relationships should be avoided.
○ These occur in situations where the member is
the HCP but also holds a different significant
authority or emotional relationship with the same
person.
○ For example, a member may also be a course
instructor, work place supervisor, family member
or friend.
Professional boundaries and moral obligation in healthcare

● Power Imbalances
○ HCP should avoid relationships with their
clients outside of the professional
relationship where either the HCP or client
is in a position to give a special favour, or
to hold any type of power over the other.
Professional boundaries and moral obligation in healthcare

● Power Imbalances
○ For example, some situations to be avoided include:
■ Employing a client or his or her close relatives;
■ Seeking professional consultation from a client
in the client’s area of expertise;
■ Involving oneself in business ventures where
one could benefit financially from a client’s
expertise or information;
Professional boundaries and moral obligation in healthcare

● Power Imbalances
○ For example, some situations to be avoided
include (cont.):
■ Engaging in therapy or conducting an
assessment with a current student;
■ Requesting favours from a client, such as
baby-sitting, typing, or any other type of
assistance that involves a relationship outside
of the established professional one.
Professional boundaries and moral obligation in healthcare

● Becoming friends
○ Generally, HCP should avoid becoming friends
with clients and should refrain from socializing
with them.
○ Although there are no explicit guidelines that
prohibit friendships from developing once
therapy has terminated, HCP must use their
clinical judgment in assessing the
appropriateness of this for the individual client.
Professional boundaries and moral obligation in healthcare

● Dating
○ The definition of “sexual abuse” within the legislation
makes it clear that it is unacceptable to date a current
client.
○ Since power imbalances may continue to influence the
client well past termination, professional standards
prohibit a HCP from engaging in a sexual relationship
with a former client to whom any professional service
was provided in the past two years, or longer.
Professional boundaries and moral obligation in healthcare

● Dating (cont.)
○ HCP are reminded that even the most
casual dating relationship may lead to
forms of affectionate behaviour that could
fall within the definition of sexual abuse.
Professional boundaries and moral obligation in healthcare

● Maintaining established conventions

○ Ignoring established conventions that help to maintain a
necessary professional distance between clients and
members can lead to boundary violations.
○ Examples include providing treatment in social rather
than professional settings, not charging for services
rendered, not maintaining clear boundaries between
living and professional space in home offices, or
scheduling appointments outside of regular hours or
when no one else is in the office.
Professional boundaries and moral obligation in healthcare

● Physical Contact
○ There are a variety of ways of using touch to
communicate nurturing, understanding and support
such as a pat on the back or shoulder, a hug or a
handshake.
○ Such touch however, can also be interpreted as sexual
or inappropriate.
○ This necessitates careful and sound clinical judgment
when using touch for supportive or other clinical
reasons.
Professional boundaries and moral obligation in healthcare

● Physical Contact (cont.)

○ HCP must be cautious and respectful when any
physical contact is involved, recognizing the diversity
of cultural norms with respect to touching, and
cognizant that such behaviour may be misinterpreted.
○ When such touch is necessary, it is important to
explain this to the client, ensure the client’s
understanding and obtain the client’s fully informed
consent.
Professional boundaries and moral obligation in healthcare

● Informal Communication and Humour

○ Miscommunication between HCP and a client
may cause the client to misunderstand a
member’s intent.
○ While it may seem harmless to make a personal
compliment about a client’s appearance, or tell a
‘racy’ joke, this type of behaviour can be
misinterpreted by a client as an interest in them
personally.
Professional boundaries and moral obligation in healthcare

● Informal Communication and Humour (cont.)

○ It is important to set a professional tone in
dealing with clients and avoid remarks of a
sexual nature (jokes, offhand comments or
use of vulgar language) that could be
overheard by a client or a member of the
public.
Relate concept of culture and the provision of culturally sensitive care

● Concept of culture
● Concept of culturally sensitive care
● Provision of culturally sensitive care
○ Approaches
○ Consideration
○ Implications
Concept of culture
● Culture can be seen as an integrated pattern of learned
beliefs and behaviours that are shared among groups
and include thoughts, styles of communicating, patterns of
interaction, views of roles and relationships, values,practices
and customs.
● Culture can be seen as an inherited ‘lens’ through which
the individual perceives and understands the world that
he/she inhabits and learns how to experience it
emotionally, and to behave in it in relation to other people,
supernatural forces or Gods, and the natural environment.
Concept of culture
● Understanding the sociocultural dimensions underlying
a patient’s health values, beliefs and behaviours is
critical to a successful outcome of a clinical encounter.
● These include variations in patient perceptions of health
and illnesses, recognition of symptoms, threshold for
seeking care, ability to communicate symptoms to a
provider, ability to understand the management strategy,
expectations of care and adherence to preventive
measures and medications.
Concept of culture
● Malaysians, comprising a multi-ethnic population of
Malays, Chinese and Indians still use a wide variety of
traditional healthcare systems in spite of having
remarkable modern rural health service.
● Patients’ perceptions of health, expectations of healthcare,
treatment choices, advances in health care, and other
aspects of care are influenced by class, culture and religion.
● HCP may be inadequately trained to face the challenges of
providing quality care to socially and culturally diverse
populations.
Concept of culture
● Understanding the different cultural background and
traditional practice of patients will help to promote
better communication and cooperation between HCP
and patients, improves clinical diagnosis and
management, avoid cultural blind spots and unnecessary
medical testing and lead to better compliance of patients
with treatment.
Concept of culturally sensitive care
● Culturally sensitive health care has been described as
care that reflects “the ability to be appropriately
responsive to the attitudes, feelings, or circumstances of
groups of people that share a common and distinctive
racial, national, religious, linguistic, or cultural heritage”.
● Culturally sensitive health care has also been described
as care in which health care providers offer services in a
manner that is relevant to patients’ needs and
expectations.
Concept of culturally sensitive care
● Providing culturally sensitive care is an important
component of patient centered-care.
● HCP must strive to enhance their ability to provide
patient-centered care by reflecting on how their and the
patient’s culture’s, values, and beliefs impact the HCP-
patient relationship.
● The HCP also must understand how bio-psychosocial
needs and cultural background relate to health care
needs.
Concept of culturally sensitive care
There are many barriers erected by cultural differences,
especially between HCP and their patients:
1. Language
2. Cultural Traditions
3. Health Literacy
4. Cultural Assumption
Concept of culturally sensitive care
1. Language
○ When HCP and their patients don’t speak the same
language, providing quality medical care and making the
patient feel comfortable and cared for can be exponentially
more challenging.
○ It can be difficult to inform a patient or be confident about
consent given when the patient primarily communicates in
their mother tongue.
○ It’s also very common for patients who are bilingual to
speak in their native language when they don’t feel well
and are stressed or scared.
Concept of culturally sensitive care
2. Cultural Traditions
○ Many cultures have very different ways of thinking about
healthcare and may have traditions that go against the grain of
Western medicine.
○ For example, a Native American man may not want to be
resuscitated or placed on life support. A woman born in Beijing
may be resistant to taking prescribed medication for a
condition and may want to use traditional Chinese herbal
remedies and acupuncture.
○ Healthcare providers who are unfamiliar with cultural traditions
surrounding medical care may have difficulty connecting with
the patient or the patient may not feel safe and recognized,
which is key to treatment acceptance.
Concept of culturally sensitive care
3. Health Literacy
○ A different understanding of healthcare from culture
to culture also affects health literacy.
○ Individuals in some cultures may not be aware of
certain health conditions or how to maintain their
health on a day to day basis.
○ When patients from different cultural or racial
backgrounds have difficulty understanding healthcare
practices, HCP have the important job of bringing
them up to speed with diagnosis and treatment in a
way that is sensitive to their cultural needs.
Concept of culturally sensitive care
4. Cultural Assumption
○ Many HCP have developed assumptions about
different cultures over time, often because
there was a fundamental lack of accurate
education about that particular culture.
○ Cultural assumptions and the lack of
knowledge of culture can create unique
challenges for both nurses and patients
Provision of
culturally sensitive
care:
1. Approaches
Provision of
culturally sensitive
care:
2. Consideration
Provision of culturally sensitive care
Implications:

1. Cultural competence is necessary because it helps the

health care workers offer the best services to every
patient, leading to high satisfaction and care on the side
of the patient. Without cultural competence, the health
sector will suffer a great loss and ultimately limit the
services that it can offer.
Provision of culturally sensitive care
Implications:

2. A strong background and knowledge of cultural

competence prevents professional health caregivers
from possessing stereotypes and being myopic in their
thoughts. It also helps them offer the best service to all,
regardless of their social status or belief.
Provision of culturally sensitive care
Implications:

3. Health care workers can strengthen their cultural

competence by pursuing continuing education, cross-
cultural interactions, or specific assessments. These
efforts help to keep their minds open and free of
judgment or preformed notions about certain cultures or
locations.
Provision of culturally sensitive care
Implications:

4. The world becomes better with more culturally

competent service providers in each sector. Culturally
competent nurses are essential to providing top-quality
services to their patients—translating to better health
care in every community.
Identify mechanism for enhancing clinical practice, professional practices
and professional development

● CPDs
● Continual learning
Mechanism for enhancing clinical practice, professional practices and
professional development

Continuing professional development (CPD) in healthcare is

fundamental for making sure frontline staff practice safely and
effectively.

This requires practitioners to update knowledge and skills

regularly to match the changing complexity of healthcare needs.

The drive towards using limited resources effectively for service

improvements and the need for a flexible workforce necessitate
a review of ad hoc approaches to CPD.
CPDs ● Continuing Professional Development (CPD) is a systematic
maintenance, improvement and broadening of knowledge,
understanding and skills, and the development of personal
qualities necessary for the execution of professional duties
throughout the individual's working life.
● CPD can involve any relevant learning activity, whether
formal and structured or informal and self-directed. With
rapid advancements in medicine, it is imperative that
healthcare professionals continue to keep themselves
abreast with new developments that would provide better
care and treatment outcomes for their patients.
Link myCPD Versi 2.0: https://www.mycpd2.moh.gov.my/
Continual learning
Pembangunan dan Latihan Penjawat Awam

Bagi meningkatkan kemahiran bekerja bagi pekerja awam, pelbagai

kursus dan latihan yang telah disediakan oleh kerajaan maupun swasta.
Kursus dan latihan yang boleh dipohon adalah seperti berikut:

1. Institut Tadbiran Awam Negara (INTAN)

2. Institut Latihan Kehakiman dan Perundangan (ILKAP)
3. Institut Latihan Islam Malaysia (ILIM)
4. Institut Tanah dan Ukur Negara (INSTUN)
5. Institut Keselamatan dan Pekerjaan Negara (IKKPN/NIOSH)
6. Program Penempatan Silang atau Cross Fertilisation Program
(PCF)
Continual learning

KURSUS LANJUTAN di ILKKM secara sepenuh masa yang

ditawarkan oleh Bahagian Pengurusan Latihan KKM:

1. Sijil Pos Basik Sediaan Farmaseutikal Steril (Post Basic

Certificate In Pharmaceutical Sterile Preparation):
○ 6 bulan
○ Terbuka untuk Penolong Pegawai Farmasi
○ Pusat Latihan di ILKKM Sungai Buloh
Continual learning
Tawaran Kemudahan Cuti Belajar / Program Latihan dengan /
tanpa Hadiah Latihan Persekutuan bagi mengikuti Kursus
Latihan dalam Perkhidmatan secara sepenuh masa ditawarkan
oleh Bahagian Pengurusan Latihan KKM:

1. Tawaran A: Terbuka kepada Kumpulan P&P lantikan KKM

untuk mengikuti Sarjana / Ph.D / Area of Special Interest
2. Tawaran E: Terbuka kepada pegawai Kumpulan Pelaksana
lantikan KKM untuk mengikuti kursus peringkat
Diploma / Ijazah Sarjana Muda
Ada soalan?