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Professional Boundary Issues in Practice
FROM THE ACADEMY
Ethics in Action
Professional Boundary Issues in Practice
P
ROFESSIONALISM IN NUTRITION and dietetics can primarily be defined as promoting patient welfare and in the process subordinating one’s own self-interest.1 In visiting a registered dietitian nutritionist (RDN), a patient has the right to expect expertise and ethical treatment. To justify the patient’s trust, the RDN uses the four basic principles of decision making as guidelines for reasoning. These are: 1.
2. 3. 4.
Autonomy: The patient’s right to personal choices as an individual. Beneficence: Do good to others. Nonemaleficence: Do no harm. Justice: Promote and exhibit fairness.2
In order to insure responsible and ethical care, the above principles are used to establish boundaries. These boundaries are the RDN’s means of monitoring himself or herself in order to prevent incompetency and impropriety when counseling or treating clients.2 “Professional boundaries are integral to good providereclient relationships, as they promote good care for patients and protect both parties.”3 “Such boundaries are parameters that describe the limits of a relationship in which one person entrusts his or her welfare to another and to whom a fee is paid for the provision of a service.”3 This article will discuss the ethical structure of boundary issues in terms
This article was written by Mindy Beth Nelkin, MS, MA, RD, vice president, MCH Group LLC, New York, NY.
of the dynamics and dilemmas of the RDNeclient relationship. The two documents that serve as resources for this article are the American Dietetic Association/Commission on Dietetic Registration Code of Ethics for the Profession of Dietetics4 and the Revised 2012 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitians.5 Nutrition and dietetics practitioners have adopted these documents as guiding principles to reflect the concerns, values, and ethics of their profession (Figure). They set forth the commitments and obligations of the nutrition and dietetics practitioner to the public, clients, the profession, colleagues, and other health professionals.4 The need to maintain professional boundaries cannot be overemphasized. The practitioner’s position must neither exploit nor pursue a relationship with any person under his or her care.3 Boundary violations are both unethical and unprofessional and can impinge upon the patient’s trust in his or her health care provider. Once lines are crossed, the patienteprovider relationship is compromised. Nevertheless, ethical care is not an exact or unequivocal science. Ethics is an exercise in moral reasoning. One’s judgment, wisdom, and empathy all come into play and are part of the professional skill set the RDN uses when diverse circumstances and relationships present themselves. “Boundary dilemmas occur when health care professionals experience conflict of interest between professional and personal aspects of their relationships with a client.”6
http://dx.doi.org/10.1016/j.jand.2015.04.007
SOCIALIZING To take the Continuing Professional Education quiz for this article, log in to www.eatrightPRO. org, go to the My Account section of the My Academy Toolbar, click the “Access Quiz” link, click “Journal Article Quiz“ on the next page, and then click the “Additional Journal CPE quizzes” button to view a list of available quizzes.
ª 2015 by the Academy of Nutrition and Dietetics.
In an investigation of boundary issues for hospice palliative care volunteers, Claxton-Oldfield and colleagues found that, “Duality or multiple relationships are inevitable.”7 Since the RDN is an individual with a personal as well as professional life, boundary complications often
arise away from the office environment. Professional boundaries may blur as part of a “slippery slope” when outside usual practice.3,8 In smaller towns and rural areas, for example, caring for friends is acceptable and even unavoidable.8 Unlike in urban settings, there is less of a buffer in rural areas between the personal and the professional self.9 Not only is the medical community smaller, but providers are also more apt to have mutual friends and shared activities. Most residents attend the same community centers, dances, and school functions. The RDN could be the high school soccer coach or the president of the parenteteacher organization. Issues of pizza parties or bake sales will inevitably arise and the RDN is put in the awkward position of promoting healthy eating habits without lecturing or providing formal nutrition counseling. Boundaries may be easier to maintain in an urban setting, yet even in these environments, people’s lives can intersect socially and professionally. It is here that the RDN practices the Fundamental Principles of the Code of Ethics, specifically Principles #1 and #2.4 The RDN always remains aware of his or her professional and personal obligations and conducts himself or herself with integrity in public.
GIFTS Besides socializing and the treating of friends and relatives, the offer and receipt of gifts in appreciation of services or at holiday season is not uncommon. Token gifts like chocolate or candles will not compromise the relationship. Money or something expensive or intimate will. It is up to the RDN to recognize these situations and to keep friendship outside of the office and professional help within. Here the RDN can refer to Code of Ethics Principle #18 that allows him or her to receive gifts of nominal value. Both parties must be aware that these gifts do not come with expectations that would influence the RDN to act in a way that would run counter to his or her professional judgment.4
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
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FROM THE ACADEMY The two Standards of Professional Performance are: Standard #1—Quality in Practice: The registered dietitian nutritionist provides quality services using a systematic process with identified leadership, accountability, and dedicated resources. Standard #2—Competence and Accountability: The registered dietitian nutritionist demonstrates competence in and accepts accountability and responsibility for ensuring safety and quality services provided. The following are the applicable Fundamental Principles of Code of Ethics: Principle #1: The nutrition and dietetics practitioner conducts him- or herself with honesty, integrity, and fairness. Principle #2: The nutrition and dietetics practitioner supports and promotes high standards of professional practice. The nutrition and dietetics practitioner accepts the obligation to protect clients, the public, and the profession by upholding the Code of Ethics for the Profession of Dietetics and by reporting perceived violations of the Code through the processes established by the Academy of Nutrition and Dietetics and its credentialing agency, the Commission on Dietetic Registration. Principle #5: The nutrition and dietetics practitioner provides professional services with objectivity and with respect for the unique needs and values of individuals. Principle #9: The nutrition and dietetics practitioner treats clients and patients with respect and consideration. Principle #10: The nutrition and dietetics practitioner protects confidential information and makes full disclosure about any limitations to guarantee full confidentiality. Principle #18: The nutrition and dietetics professional does not invite, accept, or offer gifts, monetary incentives, or other considerations that affect or reasonably give an appearance of affecting his or her professional judgment. Figure. Guiding principles to reflect the concerns, values, and ethics of the dietetics profession. Adapted from references 4 and 5.
SOCIAL MEDIA
PROVIDEReCLIENT DYNAMIC
Social media has also provided a new and frequently problematic venue for the relationships of providers and patients. Counseling, now available via the Internet, is increasing in popularity. Social networking outside the professional realm can present a boundary hazard for the RDNeclient relationship. It is important to think of the correspondence in online counseling sessions as an extension of one’s office environment and to adhere to the same guidelines practiced in the physical space. Confidentiality must be maintained. Likewise, keeping professional distance on social media with one’s client is also essential. Personal information should not be shared with a patient on Facebook, LinkedIn, or Twitter accounts. Remember that anything one puts online becomes part of the public domain. Therefore, it violates the privacy/client relationship and undermines one’s professional standing in the community. Again, the RDN should refer to the Fundamental Principles #1 and #2 of the Code4 in order to always conduct himor herself with the utmost professional behavior. He or she also respects the clienteprovider relationship and maintains confidentiality when invoking Code of Ethics Principle #10.4
It is essential to recognize the nature of the providereclient dynamic: it is not a friendship. It is, however, a partnership, albeit an asymmetrical one. The RDN is in a position of power and must recognize the vulnerability of his or her patient. Once in the provider’s office, the patient confides in the RDN, expects to receive expert and individual nutritional advice, and in turn pays for these services. An initial counseling will begin with an interview, a review of the patient’s diet history, food recall, as well as a medical history including all prescription and nonprescription medications. A plan of action is developed, followed by continuing visits to carry out the proposed plan. Throughout this process, the RDN listens to the client and validates his or her needs and goals. Code of Ethics Principles #5 and #9, respectively, support this process, stating that the RDN should maintain objectivity and respect for his or her clients as he or she provides him with pertinent and personalized care.4 RDNs also acknowledge their need to make their own decisions based on the information that clients give them.4 Most importantly this includes “consent, modification, or refusal.”4
976
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
In addition, the RDN always adheres to the Health Insurance Portability and Accountability Act (HIPAA) regulations and refrains from discussing the patient with other professionals, friends, and family members, unless otherwise directed by the patient. Similarly, the RDN does not discuss the patient with referring providers in public spaces or social situations. The RDN must always respect the privacy of the providereclient relationship. Refer to Code of Ethics Principle #10, protection of confidential information.4
Case Scenario #1 A client visits his RDN and states that he desires to eat a healthful diet. He knows he is overweight, but his current goal is only to maintain his current weight and improve his eating habits. Hoping instead to lead the patient toward weight loss, the RDN interrupts, starts to discuss her own food preferences, and continues the session by setting unwanted goals for the patient. This scenario creates conflict for the patient. It is essential that the RDN be a good communicator as well as a good listener who shows regard for her patient and his needs. The client’s ability to tell the provider about his food June 2015 Volume 115 Number 6
FROM THE ACADEMY history and eating habits should not be inhibited by adverse judgment. It is not appropriate for the RDN to discuss her personal life or to impose her personal values on the patient. When the patient feels he is not being heard, he leaves intimidated and discouraged. The RDN should have validated and encouraged the patient’s primary goal by helping with healthful food choices. Weight loss can become a future and mutual goal when the patient is comfortable with the success of his immediate objectives.
Case Scenario #2 The RDN and a client are guests at the same social function. The RDN begins to talk about a mutual friend and other people in the community. She also discusses her family life, mentioning that her husband has a weight problem and insists on eating fast food and bringing all sorts of snacks into their home. This makes the client uncomfortable. She is now burdened with too much information, which may inhibit her desire to confide in the RDN in a professional setting. The RDN who cannot influence her own husband is diminished in the patient’s eyes. The RDN should never gossip or divulge personal information to her client. A loss of the patient’s esteem is inevitable.
Case Scenario #3 The RDN is approached at a cocktail party by an acquaintance who sees the event as an opportunity for some professional advice about managing his recent diagnosis of diabetes mellitus. The RDN is not aware of his acquaintance’s new diagnosis or any other medical conditions he may have. Therefore, he is not in a position to offer any advice, especially in a social situation. If the RDN is approached by a client or an acquaintance seeking advice in a social situation, he should politely remind him that they are at a party. In order not to hurt his acquaintance’s feelings, the RDN should make clear that he cannot provide counsel without adequate information or familiarity with all relevant medical facts. If the client would like to make an appointment, they can meet in the privacy of the office setting. A social
June 2015 Volume 115 Number 6
situation is not conducive to professional counseling. Seeking and/or providing advice in this sort of situation violates the sanctity of the providerepatient relationship, which is best preserved within the parameters of the office environment.
Scenario #4 In an elevator, the provider meets a physician, who begins to discuss a mutual patient—the particulars of his case along with his name. This is a clear violation of HIPAA regulations. It is a further invasion of patienteprovider privacy and hampers trust. The RDN should remind the physician that they are in a public space and cannot continue this conversation at present. She should indicate that they could review the case in either of their offices as long as the patient provides written consent for them to do so.
client should feel free to discuss his or her dietary problems in an office setting and be confident in the RDN’s ability to preserve privacy and provide evidence-based tailored solutions. Nevertheless, as we have seen, the RDNeclient relationship is a complicated and nebulous one. It requires nuanced responses from the RDN who must temper his or her scientific knowledge and expertise with empathy for and validation of the client. This relative haziness may cause discomfort for health care professionals who prefer to work wholly in the domain of facts, evidence, and empirical data. Ethical principles are essential in allaying such unease by helping the provider to navigate potential dilemmas and to preserve a professional distance that protects both the provider’s and the patient’s respective positions. These boundaries encourage the RDN to establish, preserve, and maintain professional relationships in order to deliver optimal care.
Scenario #5 In a supermarket, the RDN meets a client who is shopping with family members. The RDN begins to talk about the patient’s progress, eyeing her shopping cart and discussing food choices. Again, this is a clear violation of HIPAA and an invasion of the client’s privacy. The RDN should be cordial, say hello and reply to the patient’s introduction, but no discussion of counseling activities should take place. The RDN can discuss the patient’s shopping habits at their next session.
References 1.
Cohen JJ. Professionalism in medical education, an American perspective: From evidence to accountability. Med Educ. 2006;40(7):607-617.
2.
Fornari A. Professional boundary issues in practice. J Am Diet Assoc. 2003;103(3):380.
3.
Bird S. Managing professional boundaries. Aust Fam Physician. 2013;42(9):666-668.
4.
American Dietetic Association. American Dietetic Association/Commission on Dietetic Registration Code of Ethics for the Profession of Dietetics. J Am Diet Assoc. 2009;109(8):1461-1467.
5.
Academy Quality Management Committee and Scope of Practice Subcommittee of Quality Management Committee. Academy of Nutrition and Dietetics: Revised 2012 standards of practice in nutrition care and standards of professional performance for registered dietitians. J Acad Nutr Diet. 2013;113(suppl 2):S29-S45.
6.
Fronek P, Kendall M, Ungerer G, Malt J, Eugarde E, Geraghty T. Towards healthy professional-client relationships: The value of an interprofessional training course. J Interprof Care. 2009;23(1):16-29.
7.
Claxton-Oldfield S, Gibbon L, SchmidtChamberlain K. When to say “yes” and when to say “no”: Boundary issues for hospice palliative care volunteers. Am J Hosp Palliat Care. 2011;28(6):429-434.
8.
Gold KJ, Goldman EB, Kamil LH, Walton S, Burdette TG, Moseley KL. No appointment necessary? Ethical challenges in treating friends and family. N Engl J Med. 2014; 371(13):1254-1258.
9.
Nelson W, Pomerantz A, Howard K, Bushy A. A proposed rural healthcare ethics agenda. J Med Ethics. 2007;33(3):136-139.
Scenario #6 A patient sees her RDN on Facebook and “friends” her. The RDN should not accept. She should explain her reasons at their next session: they have a professional relationship and conversing informally online would be inappropriate. As in Case Scenario #2, a professional distance should be maintained. Socializing online can be as compromising as socializing in person.
Conclusion This column has examined the role that ethical boundaries play in developing and maintaining a positive cliente provider relationship. The parameters of this relationship establish that the
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
977
Ethics in Action
Professional Boundary Issues in Practice
P
ROFESSIONALISM IN NUTRITION and dietetics can primarily be defined as promoting patient welfare and in the process subordinating one’s own self-interest.1 In visiting a registered dietitian nutritionist (RDN), a patient has the right to expect expertise and ethical treatment. To justify the patient’s trust, the RDN uses the four basic principles of decision making as guidelines for reasoning. These are: 1.
2. 3. 4.
Autonomy: The patient’s right to personal choices as an individual. Beneficence: Do good to others. Nonemaleficence: Do no harm. Justice: Promote and exhibit fairness.2
In order to insure responsible and ethical care, the above principles are used to establish boundaries. These boundaries are the RDN’s means of monitoring himself or herself in order to prevent incompetency and impropriety when counseling or treating clients.2 “Professional boundaries are integral to good providereclient relationships, as they promote good care for patients and protect both parties.”3 “Such boundaries are parameters that describe the limits of a relationship in which one person entrusts his or her welfare to another and to whom a fee is paid for the provision of a service.”3 This article will discuss the ethical structure of boundary issues in terms
This article was written by Mindy Beth Nelkin, MS, MA, RD, vice president, MCH Group LLC, New York, NY.
of the dynamics and dilemmas of the RDNeclient relationship. The two documents that serve as resources for this article are the American Dietetic Association/Commission on Dietetic Registration Code of Ethics for the Profession of Dietetics4 and the Revised 2012 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitians.5 Nutrition and dietetics practitioners have adopted these documents as guiding principles to reflect the concerns, values, and ethics of their profession (Figure). They set forth the commitments and obligations of the nutrition and dietetics practitioner to the public, clients, the profession, colleagues, and other health professionals.4 The need to maintain professional boundaries cannot be overemphasized. The practitioner’s position must neither exploit nor pursue a relationship with any person under his or her care.3 Boundary violations are both unethical and unprofessional and can impinge upon the patient’s trust in his or her health care provider. Once lines are crossed, the patienteprovider relationship is compromised. Nevertheless, ethical care is not an exact or unequivocal science. Ethics is an exercise in moral reasoning. One’s judgment, wisdom, and empathy all come into play and are part of the professional skill set the RDN uses when diverse circumstances and relationships present themselves. “Boundary dilemmas occur when health care professionals experience conflict of interest between professional and personal aspects of their relationships with a client.”6
http://dx.doi.org/10.1016/j.jand.2015.04.007
SOCIALIZING To take the Continuing Professional Education quiz for this article, log in to www.eatrightPRO. org, go to the My Account section of the My Academy Toolbar, click the “Access Quiz” link, click “Journal Article Quiz“ on the next page, and then click the “Additional Journal CPE quizzes” button to view a list of available quizzes.
ª 2015 by the Academy of Nutrition and Dietetics.
In an investigation of boundary issues for hospice palliative care volunteers, Claxton-Oldfield and colleagues found that, “Duality or multiple relationships are inevitable.”7 Since the RDN is an individual with a personal as well as professional life, boundary complications often
arise away from the office environment. Professional boundaries may blur as part of a “slippery slope” when outside usual practice.3,8 In smaller towns and rural areas, for example, caring for friends is acceptable and even unavoidable.8 Unlike in urban settings, there is less of a buffer in rural areas between the personal and the professional self.9 Not only is the medical community smaller, but providers are also more apt to have mutual friends and shared activities. Most residents attend the same community centers, dances, and school functions. The RDN could be the high school soccer coach or the president of the parenteteacher organization. Issues of pizza parties or bake sales will inevitably arise and the RDN is put in the awkward position of promoting healthy eating habits without lecturing or providing formal nutrition counseling. Boundaries may be easier to maintain in an urban setting, yet even in these environments, people’s lives can intersect socially and professionally. It is here that the RDN practices the Fundamental Principles of the Code of Ethics, specifically Principles #1 and #2.4 The RDN always remains aware of his or her professional and personal obligations and conducts himself or herself with integrity in public.
GIFTS Besides socializing and the treating of friends and relatives, the offer and receipt of gifts in appreciation of services or at holiday season is not uncommon. Token gifts like chocolate or candles will not compromise the relationship. Money or something expensive or intimate will. It is up to the RDN to recognize these situations and to keep friendship outside of the office and professional help within. Here the RDN can refer to Code of Ethics Principle #18 that allows him or her to receive gifts of nominal value. Both parties must be aware that these gifts do not come with expectations that would influence the RDN to act in a way that would run counter to his or her professional judgment.4
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
975
FROM THE ACADEMY The two Standards of Professional Performance are: Standard #1—Quality in Practice: The registered dietitian nutritionist provides quality services using a systematic process with identified leadership, accountability, and dedicated resources. Standard #2—Competence and Accountability: The registered dietitian nutritionist demonstrates competence in and accepts accountability and responsibility for ensuring safety and quality services provided. The following are the applicable Fundamental Principles of Code of Ethics: Principle #1: The nutrition and dietetics practitioner conducts him- or herself with honesty, integrity, and fairness. Principle #2: The nutrition and dietetics practitioner supports and promotes high standards of professional practice. The nutrition and dietetics practitioner accepts the obligation to protect clients, the public, and the profession by upholding the Code of Ethics for the Profession of Dietetics and by reporting perceived violations of the Code through the processes established by the Academy of Nutrition and Dietetics and its credentialing agency, the Commission on Dietetic Registration. Principle #5: The nutrition and dietetics practitioner provides professional services with objectivity and with respect for the unique needs and values of individuals. Principle #9: The nutrition and dietetics practitioner treats clients and patients with respect and consideration. Principle #10: The nutrition and dietetics practitioner protects confidential information and makes full disclosure about any limitations to guarantee full confidentiality. Principle #18: The nutrition and dietetics professional does not invite, accept, or offer gifts, monetary incentives, or other considerations that affect or reasonably give an appearance of affecting his or her professional judgment. Figure. Guiding principles to reflect the concerns, values, and ethics of the dietetics profession. Adapted from references 4 and 5.
SOCIAL MEDIA
PROVIDEReCLIENT DYNAMIC
Social media has also provided a new and frequently problematic venue for the relationships of providers and patients. Counseling, now available via the Internet, is increasing in popularity. Social networking outside the professional realm can present a boundary hazard for the RDNeclient relationship. It is important to think of the correspondence in online counseling sessions as an extension of one’s office environment and to adhere to the same guidelines practiced in the physical space. Confidentiality must be maintained. Likewise, keeping professional distance on social media with one’s client is also essential. Personal information should not be shared with a patient on Facebook, LinkedIn, or Twitter accounts. Remember that anything one puts online becomes part of the public domain. Therefore, it violates the privacy/client relationship and undermines one’s professional standing in the community. Again, the RDN should refer to the Fundamental Principles #1 and #2 of the Code4 in order to always conduct himor herself with the utmost professional behavior. He or she also respects the clienteprovider relationship and maintains confidentiality when invoking Code of Ethics Principle #10.4
It is essential to recognize the nature of the providereclient dynamic: it is not a friendship. It is, however, a partnership, albeit an asymmetrical one. The RDN is in a position of power and must recognize the vulnerability of his or her patient. Once in the provider’s office, the patient confides in the RDN, expects to receive expert and individual nutritional advice, and in turn pays for these services. An initial counseling will begin with an interview, a review of the patient’s diet history, food recall, as well as a medical history including all prescription and nonprescription medications. A plan of action is developed, followed by continuing visits to carry out the proposed plan. Throughout this process, the RDN listens to the client and validates his or her needs and goals. Code of Ethics Principles #5 and #9, respectively, support this process, stating that the RDN should maintain objectivity and respect for his or her clients as he or she provides him with pertinent and personalized care.4 RDNs also acknowledge their need to make their own decisions based on the information that clients give them.4 Most importantly this includes “consent, modification, or refusal.”4
976
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
In addition, the RDN always adheres to the Health Insurance Portability and Accountability Act (HIPAA) regulations and refrains from discussing the patient with other professionals, friends, and family members, unless otherwise directed by the patient. Similarly, the RDN does not discuss the patient with referring providers in public spaces or social situations. The RDN must always respect the privacy of the providereclient relationship. Refer to Code of Ethics Principle #10, protection of confidential information.4
Case Scenario #1 A client visits his RDN and states that he desires to eat a healthful diet. He knows he is overweight, but his current goal is only to maintain his current weight and improve his eating habits. Hoping instead to lead the patient toward weight loss, the RDN interrupts, starts to discuss her own food preferences, and continues the session by setting unwanted goals for the patient. This scenario creates conflict for the patient. It is essential that the RDN be a good communicator as well as a good listener who shows regard for her patient and his needs. The client’s ability to tell the provider about his food June 2015 Volume 115 Number 6
FROM THE ACADEMY history and eating habits should not be inhibited by adverse judgment. It is not appropriate for the RDN to discuss her personal life or to impose her personal values on the patient. When the patient feels he is not being heard, he leaves intimidated and discouraged. The RDN should have validated and encouraged the patient’s primary goal by helping with healthful food choices. Weight loss can become a future and mutual goal when the patient is comfortable with the success of his immediate objectives.
Case Scenario #2 The RDN and a client are guests at the same social function. The RDN begins to talk about a mutual friend and other people in the community. She also discusses her family life, mentioning that her husband has a weight problem and insists on eating fast food and bringing all sorts of snacks into their home. This makes the client uncomfortable. She is now burdened with too much information, which may inhibit her desire to confide in the RDN in a professional setting. The RDN who cannot influence her own husband is diminished in the patient’s eyes. The RDN should never gossip or divulge personal information to her client. A loss of the patient’s esteem is inevitable.
Case Scenario #3 The RDN is approached at a cocktail party by an acquaintance who sees the event as an opportunity for some professional advice about managing his recent diagnosis of diabetes mellitus. The RDN is not aware of his acquaintance’s new diagnosis or any other medical conditions he may have. Therefore, he is not in a position to offer any advice, especially in a social situation. If the RDN is approached by a client or an acquaintance seeking advice in a social situation, he should politely remind him that they are at a party. In order not to hurt his acquaintance’s feelings, the RDN should make clear that he cannot provide counsel without adequate information or familiarity with all relevant medical facts. If the client would like to make an appointment, they can meet in the privacy of the office setting. A social
June 2015 Volume 115 Number 6
situation is not conducive to professional counseling. Seeking and/or providing advice in this sort of situation violates the sanctity of the providerepatient relationship, which is best preserved within the parameters of the office environment.
Scenario #4 In an elevator, the provider meets a physician, who begins to discuss a mutual patient—the particulars of his case along with his name. This is a clear violation of HIPAA regulations. It is a further invasion of patienteprovider privacy and hampers trust. The RDN should remind the physician that they are in a public space and cannot continue this conversation at present. She should indicate that they could review the case in either of their offices as long as the patient provides written consent for them to do so.
client should feel free to discuss his or her dietary problems in an office setting and be confident in the RDN’s ability to preserve privacy and provide evidence-based tailored solutions. Nevertheless, as we have seen, the RDNeclient relationship is a complicated and nebulous one. It requires nuanced responses from the RDN who must temper his or her scientific knowledge and expertise with empathy for and validation of the client. This relative haziness may cause discomfort for health care professionals who prefer to work wholly in the domain of facts, evidence, and empirical data. Ethical principles are essential in allaying such unease by helping the provider to navigate potential dilemmas and to preserve a professional distance that protects both the provider’s and the patient’s respective positions. These boundaries encourage the RDN to establish, preserve, and maintain professional relationships in order to deliver optimal care.
Scenario #5 In a supermarket, the RDN meets a client who is shopping with family members. The RDN begins to talk about the patient’s progress, eyeing her shopping cart and discussing food choices. Again, this is a clear violation of HIPAA and an invasion of the client’s privacy. The RDN should be cordial, say hello and reply to the patient’s introduction, but no discussion of counseling activities should take place. The RDN can discuss the patient’s shopping habits at their next session.
References 1.
Cohen JJ. Professionalism in medical education, an American perspective: From evidence to accountability. Med Educ. 2006;40(7):607-617.
2.
Fornari A. Professional boundary issues in practice. J Am Diet Assoc. 2003;103(3):380.
3.
Bird S. Managing professional boundaries. Aust Fam Physician. 2013;42(9):666-668.
4.
American Dietetic Association. American Dietetic Association/Commission on Dietetic Registration Code of Ethics for the Profession of Dietetics. J Am Diet Assoc. 2009;109(8):1461-1467.
5.
Academy Quality Management Committee and Scope of Practice Subcommittee of Quality Management Committee. Academy of Nutrition and Dietetics: Revised 2012 standards of practice in nutrition care and standards of professional performance for registered dietitians. J Acad Nutr Diet. 2013;113(suppl 2):S29-S45.
6.
Fronek P, Kendall M, Ungerer G, Malt J, Eugarde E, Geraghty T. Towards healthy professional-client relationships: The value of an interprofessional training course. J Interprof Care. 2009;23(1):16-29.
7.
Claxton-Oldfield S, Gibbon L, SchmidtChamberlain K. When to say “yes” and when to say “no”: Boundary issues for hospice palliative care volunteers. Am J Hosp Palliat Care. 2011;28(6):429-434.
8.
Gold KJ, Goldman EB, Kamil LH, Walton S, Burdette TG, Moseley KL. No appointment necessary? Ethical challenges in treating friends and family. N Engl J Med. 2014; 371(13):1254-1258.
9.
Nelson W, Pomerantz A, Howard K, Bushy A. A proposed rural healthcare ethics agenda. J Med Ethics. 2007;33(3):136-139.
Scenario #6 A patient sees her RDN on Facebook and “friends” her. The RDN should not accept. She should explain her reasons at their next session: they have a professional relationship and conversing informally online would be inappropriate. As in Case Scenario #2, a professional distance should be maintained. Socializing online can be as compromising as socializing in person.
Conclusion This column has examined the role that ethical boundaries play in developing and maintaining a positive cliente provider relationship. The parameters of this relationship establish that the
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
977