Guidance on maintaining clear sexual boundaries with patients: expanding on the principles of the code of ethics
In this article, Priya Sejpal, head of ethics at the RoyalPharmaceutical Society, provides advice for pharmacists and pharmacytechnicians on maintaining appropriate sexual boundaries betweenprofessionals and patients, and what action to take if these have beenbreached
In this article, Priya Sejpal, head of ethics at the Royal Pharmaceutical Society, provides advice for pharmacists and pharmacy technicians on maintaining appropriate sexual boundaries between professionals and patients, and what action to take if these have been breached
Registration as a pharmacist or pharmacy technician carries obligations as well as privileges. It requires registrants to act in a way that promotes confidence and trust in the pharmacy profession.
The Code of Ethics for Pharmacists and Pharmacy Technicians states that registrants must make the care of patients their first concern and show respect for others.
They must always maintain proper professional boundaries in the relationships they have with patients and other individuals that they come into contact with during the course of their professional practice, taking special care when dealing with vulnerable individuals.
In January 2008, the Council for Healthcare Regulatory Excellence (CHRE) published “Clear sexual boundaries between healthcare professionals and patients: responsibilities of healthcare professionals”.
This has been used as the basis of this document and it sets out the responsibilities of healthcare professionals and details the importance of maintaining proper professional boundaries.
This guidance applies to all pharmacists and registered pharmacy technicians, regardless of the sector within which they work.
Definition of terms
A person who receives care or treatment. This does not include the provision of non-medicinal products, such as hair or beauty products.
Those who are close to the patient and who are part of their clinical experience, eg, the patient’s parent or guardian.
Acts, words or behaviour designed or intended to arouse or gratify sexual impulses or desires (see Panel).
Breaches of sexual boundaries
A breach of sexual boundaries occurs if a health professional displays sexualised behaviour towards a patient or carer. This is not limited to criminal acts, such as rape or sexual assault, but could also include accepting a date, performing clinically unjustified physical examinations and requesting details of sexual orientation that are neither necessary nor relevant.
The Panel expands on the types of sexualised behaviour that may constitute a breach of professional boundaries.
As healthcare professionals, pharmacists and pharmacy technicians must uphold public trust and confidence in their profession by acting with honesty and integrity and they must not abuse their professional position.
The consequences for patients when sexual boundaries are breached can be grave and this is wholly unacceptable. Crossing these boundaries can result in lasting harm to patients and could also result in a lack of trust in not only the pharmacy profession, but also in healthcare professionals generally.
It is possible that if a healthcare professional is sexually involved with a patient their professional judgement will be impaired. This involvement may influence decisions that they make about patients’ healthcare. It is entirely a health professional’s responsibility to ensure that proper professional boundaries are maintained at all times.
Power imbalance/cultural differences
An imbalance of power is often a feature in the healthcare professional/patient relationship, although this may not be explicit.
Patients seeking medical advice or intervention may be in a vulnerable position. The imbalance arises because pharmacists will have access to information and resources the patient needs.
The patient may also be vulnerable because they are sharing personal information with the pharmacist, and they may not know what constitutes professional practice, including the level of any physical contact that may be necessary.
Therefore, because of this potential power imbalance, it is vital that pharmacists and technicians ensure proper professional boundaries are maintained at all times.
They should be aware that cultural differences can affect a patient’s perception of what is appropriate. They should therefore be sensitive to this and treat patients in a way that reflects their own views and wishes and preserves their dignity. For example, a female patient may prefer or want to be examined by a female practitioner.
Avoiding breaches of sexual boundaries
In a situation where a pharmacist or technician is attracted to a patient or a carer they must not act on these feelings. The CHRE document details a number of behaviours that, although they do not necessarily constitute a breach of sexual boundaries, may be precursors to displaying sexualised behaviour towards patients or carers. These include:
- Revealing intimate details to a patient during a professional consultation
- Giving or accepting social invitations where this is sexually motivated
- Visiting a patient’s home unannounced and without a prior appointment
- Seeing patients outside normal practice
- Clinically unnecessary communications
Pharmacists who find themselves in a situation where they are sexually attracted to a patient and they have concerns that this may affect their professional judgement should seek guidance from the Royal Pharmaceutical Society’s Legal and Ethical Advisory Service. They may also find it helpful to discuss the matter with a colleague.
As already stated, the code of ethics requires pharmacists and pharmacy technicians to make the care of patients their first concern, so if their professional judgement is impaired they should refer the patient or carer to someone who can treat them objectively.
Pharmacists or technicians who conclude that they cannot continue to provide the correct level of care and who do not believe that they can remain objective must:
- Find alternative care for the patient
- Ensure a proper handover of care, where necessary
- Ensure the patient does not feel that he or she is in the wrong as a result of the hand-over of care to another professional
Conversely, there may be situations when patients or their carers are attracted to healthcare professionals. The CHRE document advises that where a patient displays sexualised behaviour towards a professional an appropriate course of action may be to discuss their feelings in a constructive manner and attempt to re-establish a professional relationship.
If this is not possible, the patient’s care should be transferred to a different health professional. Pharmacists and technicians in these circumstances should seek advice from the Society. They may also find it helpful to discuss the matter with a colleague. It is important that patient confidentiality is maintained in these circumstances.
Previous patients or carers
A relationship with a former patient or carer will often be inappropriate for the same reasons that a relationship with a current patient is inappropriate — the relationship may be influenced by the previous professional relationship, which will often have involved an imbalance of power. Pharmacists and technicians who think that such a relationship may develop must consider the possible future harm this may cause and the impact on their professional status. They must consider the following:
- When the professional relationship ended and how long this relationship lasted
- Whether the professional relationship consisted of a significant power imbalance
- Whether the former patient was or still is particularly vulnerable
- Whether the pharmacist or technician is exploiting a power imbalance or the knowledge or influence that he or she gained through the professional relationship to develop or progress the relationship
- Whether the pharmacist or technician is treating, or is likely to treat, any other members of the former patient’s family
No matter how consensual a relationship is, should a complaint be made, it will be the pharmacist’s or technician’s responsibility to show that they have acted appropriately and professionally. They will need to show that all the issues above have been considered and that they have sought appropriate advice.
Principle 7 of the code of ethics, “Take responsibility for your working practices”, requires pharmacists and technicians to raise concerns if policies, systems, working conditions, or the actions, professional performance or health of others may compromise patient care or public safety. They are also obliged to take appropriate action if something goes wrong or if others report concerns to them.
If they are aware that another healthcare professional has or may have breached sexual boundaries with a current or previous patient or carer then they must take appropriate action.
They should explain that they have an ethical and professional duty to take action, in order to comply with Principle 1 of the code of ethics, and that failure to take such action could amount to professional misconduct on their part.
Depending on the circumstances, they may need to alert the police, the regulatory body for the healthcare professional, the employer or the relevant primary care organisation.
Pharmacists and technicians who are approached by a patient or carer about breaches of sexual boundaries should consider how difficult it may have been for that person to approach them. They should try to answer any questions that patients might have and alert them to other sources of advice. Finally, they should advise the patient about how they can make a complaint if they want to.
There may be situations where the patient wishes to remain anonymous. In such circumstances pharmacists and technicians must report the situation as detailed above.
If pharmacists or technicians become aware of a breach of sexual boundaries, but the affected patient does not want to report the matter, they will need to use their professional judgement based on the circumstances on whether to report the matter themselves.
If they believe that there is a serious threat to the patient, to other patients or to the public at large then they must consider the consequences of not reporting the matter.
If, in their judgment, there is a serious and imminent threat to the patient’s or to another patient’s safety (or the safety of a child or vulnerable adult) they must act without delay to ensure their concerns are investigated and patients are protected. However, they must maintain patient confidentiality where possible at all times.
As healthcare professionals, pharmacists and technicians must satisfy themselves that appropriate action has been taken if a breach has or may have occurred. If the patient does not have the capacity to take the appropriate action, health professionals must do it.
In a situation where a colleague or other healthcare professional has asked for advice, but has not acted in a manner that breaches sexual boundaries, pharmacists and technicians do not have to inform anyone although it is recommended that they seek advice from the Society.
However, if they have reason to believe that patient safety has been compromised, they must take appropriate action.
When considering the need for a chaperone, it is important that pharmacists and technicians consider the patient’s desire or wish in this respect.
For example, a healthcare professional may not consider that an examination is intimate, but the patient may. Patients should be offered the choice of having a chaperone present during any examination that he or she considers to be intimate.
The need for a patient to have a chaperone is unlikely for most pharmacists. However, for those who are providing increasingly clinical roles, there may be a role for chaperones.
Pharmacists should record any discussion that they have with patients about chaperones, including when the patient declines a chaperone.
If a chaperone is unavailable, then an offer should be made to postpone any examination until such time that a chaperone is available.
Pharmacists should also consider whether the patient would like a chaperone during consultation in a private area.
The code of ethics and supplementary professional standards and guidance documents provides advice on confidentiality. Pharmacists must ensure that they obtain appropriate consent for any treatments or care that they provide and that patient confidentiality is maintained. Detailed standards on patient confidentiality and patient consent can be found in the professional standards and guidance documents on the Society’s website.
Information or advice on the professional and legal obligations of the pharmacy profession can be obtained by contacting the Society’s Legal and Ethical Advisory Service (tel 020 7572 2308, e-mail firstname.lastname@example.org).
Clear sexual boundaries between healthcare professionals and patients: responsibilities of healthcare professionals, CHRE: www.chre.org.uk
Chaperone Framework, PSNC: www.psnc.org.uk
Citation: The Pharmaceutical Journal URI: 10043388
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