Scenario 5 - Rural practice and scarcity

Max has been a nurse practitioner in his community for over 10 years. He is well-known and has a reputation for being very friendly.

Mary is completing a placement on a local farm as part of her veterinary degree requirements near the town. One day she mentions to her supervisor that she has been experiencing pain. When she’s advised to see a health care provider, Mary mentions her family nurse practitioner is in her home town which is over five hours away. Mary’s supervisor recommends she book an appointment with Max. A few days later, Mary reports for her appointment with Max and he welcomes her warmly. Once the appointment has finished, he gives her a hug. Mary leaves his office feeling perplexed; she’s never had a nurse practitioner or any other nurse hug her.

Mary remembers learning about self-regulating health professions and feels that Max’s approach to care is overly familiar. She knows this community needs his expertise and that there are limited nurses and nurse practitioners in the area. She decides to file a report with CNO. Others in town find out that Max has been reported and they are not pleased with Mary’s accusations.

Questions for discussion

  1. How would you characterize Max’s behaviour: a boundary crossing, a boundary violation, sexual abuse? Explain your answer.
  2. Would your answer to the previous questions change if you knew that most of Max’s patients are used to his overfriendly approach, and view it as acceptable?

Key concepts this scenario illustrates:

  • Rural practice and scarcity
  • Boundary violations

Max’s over-familiarity with his clientsis based on a series of recurring boundary crossings that has led to boundary violations becoming an established part of his clinical practice approach. After practicing like this for 10 years, it is unlikely that Max can objectively reflect and assess his behaviour. He may regard his behaviour and level of familiarity with his clients as normal. His clients may feel the same.

Max’s behaviour though is inappropriate. It represents boundary violations and could possibly be considered sexual abuse. Under the Regulated Health Professions Act, 1991, sexual abuse of a patient by a nurse includes touching of a sexual nature. If any of Max’s instances of touching are sexual in nature, then Max’s conduct would be considered sexual abuse.

Being in a small community with limited health care providers, most of his clients likely never had another nurse practitioner and don’t know that his decision to hug clients may violate professional boundaries.

Mary’s arrival brought fresh eyes that saw Max’s behaviour for what it was: a boundary violation. She did the right thing by reporting his behaviour. By doing so, CNO can investigate and determine how best to respond. Depending on the circumstances, CNO’s action may result in a breach of CNO’s practice standards, such as the Professional Boundaries and Nurse-Client Relationship, or a referral to the Discipline Committee on the basis of disgraceful, dishonourable or unprofessional conduct and/or sexual abuse.

It is understandable that Max’s other clients may not understand why his behaviour is wrong, but regardless of whether his clients approve or not, Max’s behaviour is inappropriate.