Boundary crossings and violation
Scenario 3 - Accepting gifts
Layla, a registered practical nurse, has been caring for resident, Kate, for many years in a long-term care facility. Kate’s grandson, Ben, has been extremely grateful for Layla’s care with his grandmother. When Ben next visits, he presents Layla with a very expensive bottle of wine to thank her for caring for his grandmother. Layla accepts the gift and says she looks forward to sampling it after work. About a month later, Ben notices that Layla is very busy with other residents and having a difficult time getting in to see his grandmother. He finds this frustrating and tells the charge nurse, “I’m surprised I can’t get timely care from Layla.” The next day, Layla receives extra help from a student nurse so has more availability to see Kate. Ben is so grateful, he brings her another gift when he comes to visit; this time it’s an annual subscription to Wine Monthly that comes with a limited edition set of wine glasses.
Questions for discussion
- Was it okay for Layla to accept the gift? Why or why not?
- What if Ben brought in a box of chocolates for the unit?
- What if Ben had made Layla a zucchini loaf instead?
- Would you consider this to be a boundary crossing or a violation? If so, which? Why?
- What if this situation was reported in the newspaper or seen on social media? How might this affect public perception of the profession?
- Would it be okay for Layla to accept the annual subscription as a thank you gift from Ben?
- How might Ben interpret Layla’s acceptance of a second gift?
Key concepts this scenario illustrates:
- Patient may interpret the meaning of gifts differently than the nurse
- Increased risk of slippery slope scenario
- Perception of preferential treatment over time
This case demonstrates how a thank you gift can blur professional boundaries. When a nurse is presented with a gift, it is important to reflect on how the patient and others may perceive the nurse accepting that gift. There may be meaning attributed to its acceptance, and conclusions drawn about the nurse-patient relationship that go beyond what is appropriate in a professional relationship.
Accepting the expensive bottle of wine, Layla crossed a boundary and opened herself up to Ben possibly feeling his grandmother was entitled to special or preferential treatment, because accepting the gift changes the relationship dynamic from professional to friendship. This was evident when he declared surprise that his grandmother was not receiving timely care from Layla and confirmed in his mind when Layla was more available the following shift. If Layla accepts the second gift (magazine subscription and limited-edition glasses), her actions confirm for Ben that his relationship with Layla is more like a friendship and he can expect to continue receiving special treatment for his grandmother as long as the gifts keep coming.
To maintain appropriate boundaries with Ben and his grandmother, Layla needs to address this head on when presented with a gift. She could do this by saying, “Thank you for your kindness Ben, but I chose to see your grandmother because I am assigned to her care and her health is important to me. There is no need for thank you gifts, as lovely as they are. I cannot accept gifts from you or any of my residents because it may be misinterpreted and I don’t want to put our professional relationship at risk”.
The considerations with accepting a gift, and the potential impact on professional boundaries, are not limited to expensive gifts. A smaller gift that can be shared with staff may not be as troubling (for example, box of chocolates, homemade goods or home grown fruit), but the need to critically assess how accepting gifts may be interpreted by the patient and others remains. A sharable gift once in a while would likely be interpreted differently than a sharable gift from a patient on an ongoing basis. This is because a gift provided on an ongoing basis could be interpreted as a way to get preferential treatment from the nurse and staff or leave the impression with the patient that the relationship is personal rather than professional.
