Maintaining Professional Boundaries

Posted on by Carole Hamp

The therapeutic relationship between an RT and his/her patient/client is one of empathy, trust and respect. It is important to acknowledge that there exists within this relationship an inherent power imbalance.  The RT has access to specialized knowledge, privileged information that the patient/client does not have.  The RT also has the ability to advocate on behalf of the patient/client. Therefore, it is essential that RTs respect the relationship they have with their patient/client though effective communication, patient/client centered care and the maintenance of professional boundaries.

In a therapeutic relationship with a patient/client, the best interests of that individual always come first, unless doing so would endanger the welfare of others. The patient/client’s vulnerability places the obligation on the RT to manage the relationship appropriately. Examples that the RT may be crossing professional boundaries in the RT’s therapeutic relationship are:

  • Disclosing personal problems to a patient/client;
  • Accepting gifts from a patient/client that could potentially change the nature of the relationship and influence the level or nature of care; or
  • Spending time outside the therapeutic relationship with a patient/client.

RTs also have professional relationships with all other members of the healthcare team with whom they interact with as they carry out their duties.  In some of these relationships, a power imbalance mirrors that in the RT’s therapeutic relationship (e.g., staff RT supervising Student RTs, Charge Therapist overseeing newer staff RTs).  It is essential for the RT to adhere to the same standard for the maintenance of these professional relationships as they do in their therapeutic relationships.

The RT Difference in End-of-Life Care

Posted on by Carole Hamp

Lately, there has been a great deal of discussion in the news, in the courts and more recently in parliament, regarding “end-of-life”. Just last week, Manitoba Conservative MP Steven Fletcher tabled a private member’s bill that proposes the enabling of “assisted dying”. Mr. Fletcher, who was left a quadriplegic after a car accident, was interviewed on the radio which I had the opportunity to listen to. It was intriguing to hear about the topic of “assisted dying” from the perspective of someone who at one time found himself caught between death, and a life that was not of his choosing.

You may also recall the Rasouli vs. Sunnybrook case that sparked a national debate about healthcare professionals providing what they deem to be “futile” care. The Supreme Court ruled that doctors could not withdraw life support with without consent from the patient’s family (substitute decision maker).

My intent in raising this issue is not to discuss the relative merits or pitfalls of assisted death, but rather to highlight the essential role that RTs play to ensure that the end of their patient’s life is as dignified as possible. We may or may not have been part of the conversation with the patient and their family about the decision to stop treatment; however, we are often the healthcare professional standing at the bedside withdrawing the life support. There was a commentary in The Globe and Mail last week stating that “often, the dying aren’t afraid of death – but of dying badly”.i  Therefore, how an RT interacts with the patient and supports the family at this very difficult time is immensely important.

If we consider the process of dying from the perspective of the patient and their family (many of whom likely have little experience with hospitals or the dying process), it’s easy to understand that what we say is just as important as what we do. Carefully explaining to the patient (regardless of whether we think they can hear us or not) and their family about what is going to happen and what to expect seems like such a little thing. But simple explanations and clear communication go a long way towards easing the anxiety and uncertainty surrounding death – and can make a very big difference.

 

i Renzetti, E. (2014, March 31). While we hesitate, the terminally ill are denied a peaceful end. The Globe and Mail.

Are We Ready for What’s Going to Happen Next?

Posted on by Carole Hamp

This November, Respiratory Therapy will have been regulated in Ontario for 20 years. In that time, as well as all the years before the CRTO came into being, we have witnessed tremendous growth in our profession.  The most dramatic changes have occurred in the acute care setting, where RTs are now performing procedures and fulfilling roles that weren’t even conceived of 20 years ago.  We know that medical advances will continue, with every reason to believe that the RT role in acute care will evolve along with them.  There are many other ways RTs can make significant differences in the lives of their patients, however most opportunities to grow as a profession now exist outside the walls of a hospital.

Demographic and financial realities will cause a dramatic shift in how health care services are delivered in this province over the next several years. One of the principal goals in the Ministry of Health and Long Term Care’s (MOHLTC) Ontario’s Action Plan for Health Care is to find cost effective ways to provide timely and high quality health care closer to home. The “Right Care, Right Time, Right Place” initiative is aimed at expanding practitioners’ scope of practice so that patients can receive the care they need in the place they choose.  As patients with increasing complex respiratory needs are being discharged from hospitals, RTs are being asked to apply a broader range of acute care skills in a community setting. This presents a unique opportunity for RTs to use their specialized knowledge and have a tremendous impact by fulfilling a very real need.  But for many of us, it will require a significant shift in how we practice individually, as well as how we see ourselves as a profession collectively.

Traditionally we’ve tended to view respiratory therapy as technology-focused and acute care-centred. However, as the population ages and more Family Health Teams (FHTs), community-based specialty clinics and long-term care facilities require RT services, we must be willing to work and (to borrow from Apple’s advertising slogan…) “think differently”. For some RTs already out in practice, it may mean learning a new skill…or dusting off an old one.  For new grads, it means considering a much broader range of practice setting options than ever before.  For example, the trach we previously changed in the ICU will now, more than likely, be changed in the person’s home. 

No matter where we work – or how long we have been working – RTs need to be ready for what may be the biggest evolution in our profession yet. 

When Silence is Not Golden

Posted on by Carole Hamp

Recently, a Toronto anesthesiologist had his certificate of registration revoked by the College of Physicians and Surgeons of Ontario (CPSO) and was criminally sentenced to 10 years in prison for assaulting a number of female patients.  Most of the offenses allegedly occurred in a busy hospital operating room while the patients where under anesthetic. I have no first-hand knowledge of this particular case or of any of the circumstances that surrounded it.  I mention it merely as an example where a health care professional failed to uphold even the most basic standards of their profession – and of society.  When a transgression like this occurs in the midst of a team environment, we are all left to wonder “how could that happen” and “what could have been done to prevent or stop it?”

Dr. Patricia Houston, president of the Canadian Anesthesiologists’ Society, spoke recently about the case on CBC Radio’s Metro Morning.  She said that it illustrates the “collective responsibility” all health care professionals have to safeguard the patients in their care[1].  It is important to remember that it cannot be assumed that someone else will bring a concern forward to the appropriate people or agency.  Admittedly, it can be challenging to report a coworker, especially if there are suspicions that something is not quite right but there’s no clear cut evidence.  An RT may feel that voicing their concerns will invite retaliation and make them appear disloyal to the team. They may also worry about damaging a colleague’s reputation if their concerns turn out to be unfounded. However, an RT’s primary accountability is to the patients receiving services within their organization and all patients are entitled to receive safe, competent and ethical care.

Fortunately, there are several avenues that an RT can take if they feel another health care professional has behaved inappropriately or failed to provide the appropriate standard of care.  First, if the conduct of the individual places patients in imminent danger, then the RT must immediately alert the appropriate person or department within their organization.  If the colleague is a member of a regulated health care profession, the RT should also contact that person’s regulatory College.  It is each health regulatory college’s duty to investigate complaints and determine if the cases merit further action.  If an RT wishes to remain anonymous, it’s best to contact the relevant College and find out what options they have.  There are often ways that Colleges can investigate an individual’s concerns without revealing their identity.

Patients need our support and advocacy…not our silence.



[1] Canadian Broadcasting Corporation. (2014, February 25). Dr. George Doodnaught gets 10 years for sex assaults. Retrieved from http://www.cbc.ca/news/canada/toronto/dr-george-doodnaught-gets-10-years-for-sex-assaults-1.2550308.

Emerging RT Practice

Posted on by Carole Hamp

Balance in emerging practiceThis year marks 20 years that RTs have been regulated health care professionals in Ontario, and some of you, like me, can trace your practice back even further than that.  An awful lot has changed in that time – and I anticipate that there are more changes yet to come.  Twenty years ago, being an RT was pretty straight forward…with ventilator/airway management, oxygen therapy, bronchodilator treatment and cardiac/respiratory arrests making up a good chunk of what we did.  But now RTs do so much more.  Some are being crossed-trained with nursing in emerg, ICU, and on rapid response and neonatal transport teams.  We’re also receiving delegation for procedures that take us well “below the diaphragm” and to the outer limits of our scope of practice, which according to the Respiratory Therapy Act (RTA) is:   

The practice of respiratory therapy is the providing of oxygen therapy, cardio-respiratory equipment monitoring and the assessment and treatment of cardio-respiratory and associated disorders to maintain or restore ventilation. (RTA, 1991, s.2)

To survive and sustain itself, our health care system needs to find new ways to provide optimal patient care by making the best possible use of our finite human and financial resources.   Everyone in health care is being asked to do more with less and RTs are now taking on roles never conceived of when the RTA was drafted.  All of this is being done to provide patients with access to the care they need, but it can make it difficult to determine if these tasks are still within the respiratory therapy scope of practice of.  For example, administering Ventolin via inhalation in emerg is a core practice clearly within the RT scope of practice – you don’t even need to think about that one.  Other tasks, such as giving IV Fentanyl for procedural sedation, sit at the outside edges of our scope.  As an RT, you can potentially do these things but it first requires some careful consideration.

Our scope of practice is not just derived from the RTA or any other single element.  The professional scope of Respiratory Therapy also comes from our education, our experience and from our practice settings.  Therefore  if we begin with the end in mind –  the provision of safe, competent and ethical patient-centred care- then the overriding issue becomes not “can I do that?” but rather “should I do that?”  The following are some factors to consider when asking yourself that question:

  • Do I have the necessary training and knowledge-base not only to perform the task, but to also manage any potential complications that might arise? (Basically, “…do I know as much about Fentanyl as I do about Ventolin?”) .  And how will I maintain my skills?
  • If something was to go wrong, would I be able adequately explain why I was the best person to perform the task at this time?
  • Is this task something that I, my department and my employer see as being as the best use of my knowledge and skills?

As we move forward into the next 20 years of our profession, we will need to continually strive to create and recreate a balance between the growing demands of the health care system and what is (defensibly) in our patient’s best interest.

Our New Practice Blog

Posted on by Carole Hamp

Welcome to the NEW Professional Practice Blog. I’m Carole Hamp, the Manager of Quality Practice at the CRTO. I can’t believe it but I have been an RT for almost 29 years; having spent over 22 years at the bedside before joining the CRTO team in 2007. I started off as the Professional Practice Advisor and then moved on to be the Manager of Quality Assurance & Member Relations. Now my role is fusion of the two services and so my new title is Manager, Quality Practice.  

During my time at the CRTO I’ve come across a lot of interesting and challenging professional practice scenarios posed from Members, employers and other health care professionals.  Many questions are fairly straight forward and fit easily into a particular standard, policy or legislative requirement.  However, there are a number of situations where there is no clear-cut answer and these are the types of issues I would like to share with you in this blog.  My hope is that these postings will generate some interesting discussions around the staff room table.

Twice a month, around the second and fourth weeks, I will post an entry related to professional practice that I’ve either encountered or think may be of interest to you.  As RTs, this is a place for you to share experiences or ask questions, and I encourage you to participate in the conversation using the comments area. As always, you may also contact me directly at the CRTO via email or phone.

Look for new posts on the website and promoted in the monthly e-bulletin and on Twitter. If you have a situation or professional practice idea you’d like to see on the blog, please do let me know!

Thanks for reading, look for my next post on February 24!

Cheers,
Carole