Scenario 6 - Incompetent practice

Brian is a registered nurse who provides psychotherapy to Ms. Khan. Brian mentioned to Ms. Khan that massage is a helpful way to help her connect to him as a RN psychotherapist, and to relax into her memories. Brian frequently massaged Ms. Khan’s body during sessions and would end each session with a long hug.

Ms. Khan had never received psychotherapy before, so she trusted that touching was clinically indicated as part of the therapy. It wasn’t until Ms. Khan discussed her therapy sessions with her friend that she realized it was not the norm for nurses to engage in massage or to hug their patients the way Brian did with her. On reflection, Ms. Khan thought Brian was touching her sexually, realizing that his breathing was laboured as he touched her, and she was extremely embarrassed and upset.

Ms. Khan had a follow-up appointment with her nurse practitioner, Joan, to discuss the progress of her psychotherapy sessions. Joan asks Ms. Khan about her experiences in psychotherapy and whether she feels this type of therapy is helping her. Ms. Khan explains that she is feeling strange about Brian’s use of massage in her therapy and mentions that he often hugs her as well. Hearing Ms. Khan’s account of Brian’s conduct is alarming to Joan who knows how important it is to maintain appropriate boundaries, and that nurses shouldn’t touch patients sexually.

Questions for discussion

  1. How would you describe Brian’s behaviour to­ward Ms. Khan? Was it appropriate or inappropri­ate? Explain your answer.
  2. Is it ever ok to physically touch a patient in a psychother­apeutic relationship? Explain your answer.
  3. If you were Joan what would you do in this instance?

Key concepts this scenario illustrates:

  • Boundary violations and sexual abuse
  • Incompetent practice
  • Duty to report

This case is a clear example of a nurse breaking the trust required to maintain a healthy nurse-patient relationship. Brian touched Ms. Khan without having any clinical indication to do so. Brian also told Ms. Khan that massage is a helpful way to help her connect to him as her psychotherapist. This information fostered Ms. Khan’s compliance and normalized Brian’s physical touch. However, Brian’s information was inaccurate. A therapeutic relationship does not require touch and may or may not positively contribute to patient care. Ms. Khan was under no obligation to consider physical touch as a component of her psychotherapy. Brian was unethical to suggest a massage. The fact that Brian frequently massaged Ms. Khan’s body with laboured breath during sessions and would end each session with a long hug, suggests the touching was sexual in nature. Brian’s actions violate boundaries and is sexual abuse. Brian may have his certificate of registration revoked because of his actions.

There may be times in a treating relationship where nurses use limited touch in order to comfort a patient: a touch on the arm or hand. Nurses must always exercise caution in doing so and ensure patient consent before touching. There is great potential for patients misinterpreting the nurse’s actions or motivations. Nurses must never touch patients for a sexual purpose.

As a peer, you would have a duty to report Brian’s actions if you became aware of them because what he is doing suggests sexual abuse of a patient. It is unprofessional behaviour that, by law, you are required to report to CNO.