This case concerns the care provided by a registered nurse to a man who was admitted to a hospital inpatient mental health unit. It highlights the importance of professional boundaries and ethical standards when communicating with, and caring for, vulnerable consumers.
The man complained to HDC that the nurse (RN1) crossed professional boundaries and became over-involved in his care. The complaint included allegations of inappropriate physical and sexual contact and behaviour, inappropriate communication, and an allegation of sexual assault during a teaching procedure on self-catheterisation.
The man was admitted to the hospital inpatient mental health unit due to concerns about changes in his mood and behaviour. At the time of his admission, he was subject to a compulsory treatment order under the Mental Health Act 1992. The man also presented with other complex clinical issues, including ongoing bladder retention, which required temporary insertion of a urinary catheter.
RN1 assisted the nursing and medical team with the management of the man’s daily care and clinical needs. She also provided clinical support and management of the man’s catheter and urinary retention issues. Prior to the man’s discharge, the nurse taught the man self-catheterisation[1] to help manage his urinary retention at home.
RN1 denied acting or behaving inappropriately towards the man during his admission and denied that the communication and manner used was inappropriate.
RN1 also denied the allegation of sexual assault and any inappropriate behaviour in relation to the self-catheterisation teaching procedure. She told HDC that a chaperone had not been available largely due to COVID-19 lockdown procedures, and it had been confirmed with the man that he wanted to proceed with the self-teaching procedure without a chaperone prior to his discharge meeting. RN1 said that the self-teaching procedure was conducted in accordance with the hospital’s Urethral Catheter Management policies. However, in hindsight, she acknowledged that she should have insisted on a chaperone being present during the procedure.
The man told HDC that he received numerous text messages from RN1, which he interpreted to be flirtatious and sexual in nature. RN1 told HDC that prior to discharge, she gave her work number to the man so that he could contact her if he had any concerns about his catheter prior to the district health nurses contacting him once he was discharged home. RN1 said that the text messages she exchanged with the man over a two-day period following his discharge, reflected the way she would usually converse with patients and staff on the ward. However, in hindsight, she accepted that she went beyond what was expected and what was appropriate in her text message communications with the man. RN1 recognised that this case highlighted how her previous approach to communication with patients could be misconstrued or misinterpreted. RN1 accepted that she became over-involved with the man’s welfare and care.
Findings
The maintenance of professional boundaries is an integral part of the provision of health services, and nurses are required to comply with the Nursing Council of New Zealand Code of Conduct and Guidelines on Professional Boundaries.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell considered that the nurse (RN1) failed to provide services to the man that complied with professional, ethical, and other relevant standards in relation to her text messages, and that the nurse’s conduct contravened professional boundaries and ethical standards. As such, the nurse was found in breach of Right 4(2)[2] of the Code of Health and Disability Services Consumers’ Rights.
Recommendations
Dr Caldwell recommended that RN1 undertake training/education on identifying and maintaining professional boundaries, in conjunction with, or endorsed by, the Nursing Council and provide HDC with detailed written evidence of discussions, case reviews, and reflections on boundary issues with patients covered in supervision.
RN1 provided evidence that the recommendations had been completed.