Dental Assisting Therapeutic Relationships and Professional Boundaries Guide

These guidelines provide information and guidance for appropriate boundaries in the relationships between health care professionals and their patients.

It is critical for dental assistants to recognize the difference between therapeutic relationships and non-professional relationships.¹ Establishing appropriate boundaries protects everyone; the patient, health care worker and others.

1. See Appendix A

A therapeutic relationship is one that places the patient and their needs first and foremost. Dental assistants will not exploit the professional relationship for fulfillment of personal needs, personal gain or satisfaction. Boundaries for professional or therapeutic relationships consider these components: power, trust, respect and closeness.

Power

Every therapeutic relationship has an imbalance of power. In the dental assistant/patient relationship the dental assistant holds the balance of power due to their position as a health care provider, specific dental-related knowledge and the patient’s dependence on the dental assistant to provide the care needed. Dental assistants have access to personal information about the patient and have influence over the treatment provided.

Patients may feel vulnerable because they must depend on the dental team including the dental assistant and trust they will receive appropriate care in the patient’s best interest. The health care team, including the dental assistant, must instill confidence the services they provide are in the best interests of the patient including considering patient participation when making treatment choices.

Trust

As discussed in the previous section, patients are vulnerable. They assume the dental assistant has the knowledge, skills, abilities and professional judgment to provide the services the patient needs. The dental assistant has a responsibility to not harm or exploit the patient and to work in the patient’s best interest. Trust that is lost through poor quality, exploitative or harmful care is not easily re-established.

Respect

Dental assistants must treat all patients with dignity and respect regardless of gender, race, or religious, cultural, physical, social, economic, political or educational background. Dental assistants must respect patients’ rights to be involved in their own care and recognize factors affecting patient decisions.

Dental assistants ensure patients have all the necessary information to give informed consent and recognize that patients may withdraw their consent at any time.

Closeness

Therapeutic relationships place individuals in positions requiring close physical proximity, revelation of emotional or sensitive personal information and psychological (e.g. fears and phobias) disclosure; a closeness not normally experienced in everyday casual encounters. Dental assistants establish boundaries to ensure this closeness is not misinterpreted or misused.

Professional boundaries are necessary to ensure the full benefit of care is focused on the patient. Professional boundaries set limits and clearly define the safe, therapeutic connection between the dental assistant and the patient. Well-defined and respected boundaries empower patients to feel a sense of participation and control in their own health care.

Some boundaries are clearly established in legislation such as the Alberta Human Rights Act, while other boundaries are established by the regulatory bodies through regulation, practice standards and codes of ethics and/or codes of conduct. Dental assistants must exercise professional judgment in establishing therapeutic relationships with each one of their patients.

Dental assistant/patient relationships that lead to abuse, harassment, romantic or sexual relationships are never appropriate. The College of Alberta Dental Assistants is fully committed to investigating all forms of unprofessional conduct that occur in dental assistant/patient relationships.

Boundary Crossings

Boundary crossings occur when the behaviour of the dental assistant deviates from the accepted boundaries of a therapeutic relationship. Normally, behaviours such as giving or receiving gifts and self-disclosure are not part of dental assisting practice or the provision of dental care and are generally inappropriate behaviours in a therapeutic relationship.

Dental assistants must reflect on behaviours that fall outside of normal and monitor for warning signs of boundary crossing.² Dental assistants must ensure their behaviours are focused on fulfilling the established treatment goals for the patient.

Boundary Violations

Boundary violations are deliberate inappropriate behaviours on the part of the dental assistant that violate the therapeutic relationship.³ These behaviours do not contribute to fulfilling the established treatment goals for the patient and are never acceptable.

2. See Appendix B
3. See Appendix C

Establishing Therapeutic Relationships

Interactions with patients can be illustrated on a continuum that identifies the limits between therapeutic and non-therapeutic behaviours. For effective patient care there exists a zone of helpfulness in which the therapeutic relationship occurs. The zone of helpfulness varies with each patient, circumstance, health condition, environment and characteristics of the patient and the dental assistant.

Assuring the Limits of the Therapeutic Relationship

Appropriate professional boundaries are established and maintained when the dental assistant practices to the standards set in the Standards of Practice, Code of Ethics and the Competency Profile for Alberta Dental Assistants.

This includes:

• compliance with all legislation pertaining to dental assisting, professional obligations and any legislation impacting practice and conduct;
• understanding the difference between professional therapeutic relationships and non-professional (personal, social, romantic) relationships;
• understanding communication styles and actively using communication strategies to maintain professional boundaries;
• using a reflective approach to practice including continuous self-assessment of one’s behaviours and interactions to ensure professionalism, integrity and respect are always demonstrated toward patients;
• understanding and setting personal and professional boundaries;
• understanding each patient’s characteristics including their personal boundaries;
• actively managing all situations that may fall outside acceptable limits of a therapeutic relationship;
• promoting patient participation and choices in care through informed decision making and informed consent;
• focusing on the patient and their defined treatment plan and dental health goals; and
• understanding the laws governing privacy, confidentiality and explaining the limits of confidentiality of personal and health information (i.e. third-party payers, members of the health care team, relevant authorities).

From: College and Association of Registered Nurses of Alberta Professional Boundaries for Registered Nurses: Guidelines for Nurse/Client Relationships 2005 And National Council of State Boards of Nursing 1995

This picture provides a visual image of therapeutic vs. non-therapeutic relationships. Beginning with under-involvement on one extreme to over-involvement on the opposite end. Under-involvement includes dental assistants distancing themselves from the patient and disinterest or neglect of the patient and the patient’s care. At the opposite end is over-involvement including boundary crossings, boundary violations and sexual misconduct.

In the centre is the “Zone of Helpfulness” where therapeutic relationships exist. The vast majority of dental assistant/patient interactions fall within the “Zone of Helpfulness”. These are the safe therapeutic connections between the professional and the person seeking care.

There may be times when a dental assistant intentionally crosses a professional boundary to benefit the therapeutic relationship. When the actions, such as self-disclosure, fall outside of what is normal in the therapeutic relationship, the dental assistant needs to consider the following questions prior to crossing the boundary:

• Am I doing something for the patient that the patient needs in order to meet the agreed-upon treatment goals?
• Who benefits most from what I am doing?
• Do I benefit in any way from what I am doing, including financially?
• Can this need be met in any other way or with other resources?
• Is there potential for my actions to confuse the patient or could they be considered inappropriate in a therapeutic relationship?
• What will the patient gain by my actions?
• What would another reasonable, professional dental assistant do in similar circumstances?
• Would I tell my colleagues or my employer about what I am doing?
• Does what I am doing create a real or perceived conflict of interest?

In situations where there is potential for the dental assistant’s actions to be questioned and/or misinterpreted, it is up to the dental assistant to ensure the patient does not misunderstand or develop an unusual dependency or unreasonable expectations of the patient/dental assistant relationship. If a boundary is crossed it is up to the dental assistant to re-clarify and re-establish the boundaries. Where this isn’t possible, the dental assistant may have to discontinue the patient/dental assistant relationship by having a colleague provide the required health care services for the patient. Speaking with the employer and/or trusted colleagues may help the dental assistant to determine the best strategy to maintain boundaries and ensure the patient’s welfare remains first and foremost.

There are occasionally circumstances where behaviour normally considered inappropriate in a therapeutic relationship may actually be beneficial to the patient.

Self-disclosure

Normally it is inappropriate for a dental assistant to disclose details of their personal lives to patients. Talking about ourselves takes the focus away from the patient and their needs. However, consider the following:

Mary has seated an elderly patient in the dental chair and begins to discuss the treatment for the day, seeking to confirm consent. The patient seems unsure about the proposed treatment and discloses that since her husband passed away, just a short time ago, she has experienced difficulty making decisions. Mary tells the patient of her own mother’s similar reaction after Mary’s father passed away and tells the patient that talking with a counsellor helped her mother to work through her feelings of loss and learn to cope with difficult decisions.

Mary has revealed just enough to validate the patient’s feelings and to provide an option for the patient to consider in learning to cope with the loss. This disclosure will not likely change the therapeutic relationship.

Accepting Gifts from Patients

Dental assistants must never expect or encourage gifts from patients, however, there may be times where it is socially or culturally appropriate to accept a gift. Consider the following:

A patient has been receiving treatment frequently over the course of a few months and Mary has been the dental assistant for most of the appointments. Mary has had significant impact helping the patient cope with a deep-seated fear of dentistry. Mary has been encouraging, patient and kind. The patient brings Mary a small bouquet of flowers with a card expressing gratitude at the final treatment appointment.

This token of thanks is not likely to change the patient/dental assistant relationship or create an expectation of special treatment in the future and is probably fine for Mary to accept.

On the other hand, what if the patient had offered Mary and her family the use of the patient’s condo in Hawaii for two weeks at no charge? Mary would have to graciously decline the gift because the value of the gift far exceeds a token of appreciation. There is potential for such a grand gift to change the therapeutic relationship and create expectations for a different standard of care.

Treating Friends, Family and Acquaintances

Sometimes dental assistants find themselves in situations where they are providing services for family and friends. This can create difficulties in clearly defining the boundaries of the therapeutic relationship. It may even appear there is a conflict of interest. Consider the following:

Mary, a dental assistant, and her neighbour, Joan, have a mutual acquaintance named Ramona. Joan knows Ramona was having trouble with a tooth and was scheduled for an extraction. Joan sees Mary outside in the garden and comes over to ask Mary how Ramona’s extraction went. Mary must maintain professional boundaries and respect Ramona’s right to privacy. Mary tells Joan she must ask Ramona for that type of personal information. Mary has respected the therapeutic relationship by protecting Ramona’s privacy.

Treating family members such as a spouse or children happens frequently for dental assistants, however, if the dental assistant experiences difficulty in carrying out the dental treatment or in helping the patient to make informed choices (bias, personal rather than professional concern, etc.), the dental assistant must consider referring the patient to a colleague who can provide the services within a therapeutic relationship and appropriate boundaries without bias.

Dental assistants need to establish and maintain appropriate therapeutic relationships with patients to ensure safe, effective and ethical care. This means dental assistants respect the nature of therapeutic relationships and continuously strive to find the right balance between open, friendly communication and over- or under-involvement with patients.

Dental assistants will place the patient’s interest first, establishing and maintaining therapeutic relationships that focus on the best outcomes for the patient.

Professional vs Non-Professional Relationships

Boundary Crossing Warning Signs

There may be warning signs a dental assistant has or may be about to cross a boundary. Some warning signs include:

• spending time with the patient beyond the scheduled dental appointment or normal office hours;
• providing the patient with your personal contact information;
• sharing personal information with the patient;
• swapping patient assignments, or providing less thorough care to one patient to allow more time with the patient;
• acting or feeling possessive about the patient;
• providing a different standard of care to that particular patient than to the rest;
• keeping secrets with the patient;
• responding defensively or guardedly when questioned about interactions with the patient;
• selective rather than complete record keeping or reporting;
• making exceptions to office rules and protocols for the patient;
• denying that the patient is a patient; and/or
• denying you have crossed a boundary from a therapeutic relationship to a non-therapeutic relationship.

Boundary Violations

There are some behaviours that are NEVER acceptable in a therapeutic relationship because they are harmful and counterproductive to meeting the patient’s needs. Any form of abuse is unacceptable. Abuse breaches trust and has no part in patient care.

Emotional/Verbal Abuse

Dental assistants must avoid verbal and non-verbal communications which may be considered by a reasonable person to be discriminatory, disrespectful, or abusive. Examples of verbal and non-verbal abusive behaviours include, but are not limited to:

• sarcasm
• manipulation
• teasing or taunting
• retaliation
• intimidation including threatening gestures or actions
• profanity
• cultural slurs
• disrespectful comments
• insensitivity to patient preferences
• inappropriate tone of voice such as anger, impatience, exasperation

Physical Abuse

Dental assistants must avoid treating patients in a manner that may be perceived as violent, threatening or may inflict pain and/or physical harm. The dental assistant must avoid rough treatment and the use of force.

To avoid the misconception of force or roughness, the dental assistant should develop simple signals the patient may employ if they feel the need to stop or take a break in treatment due to discomfort, pain or adverse reaction to treatment. When dental assistants are employed in settings where patient behaviours may be unpredictable, the dental assistant should seek additional education, training or mentoring in dealing with difficult patients without force or rough treatment.

Sexual Abuse

Sexual abuse of a patient by a dental assistant is unprofessional conduct. Even if the patient initiates a sexual relationship, the dental assistant is responsible and accountable for maintaining the boundaries of the therapeutic relationship. The crossing of boundaries may begin with seemingly innocent comments or disclosures which escalate into more. The progression of crossing the boundaries to violating the boundaries can be subtle. The dental assistant must be ever vigilant to subtle behaviours that could lead to boundary crossing or violation.

Behaviours that may be considered by the patient or a reasonable person to be sexual abuse include, but are not limited to:

• physical sexual relations
• touching of a sexual nature
• behaviour and/or remarks that may have a sexual connotation
• suggestive, seductive, exploitative, derogatory or humiliating behaviours/comments

Financial Abuse

In the provision of dental assisting services, dental assistants must avoid engaging in activities that could result in monetary, personal or material benefit, gain or profit for the dental assistant, and/or in monetary or personal loss to the patient.

Financially abusive behaviours include, but are not limited to:

• unethical or dishonest billing practices
• encouraging patients to purchase items or services not directly related to their treatment goals and resulting
  in financial or other material gain for the dental assistant
• accepting gifts from patients that exceed tokens of appreciation

Neglect

Neglect occurs when a dental assistant fails to meet the basic needs of the patient. Behaviours demonstrating neglect include, but are not limited to:

• ignoring the patient’s needs
• withholding information
• withholding services or providing less than standard of care
• ignoring patient’s rights

Discrimination, Bias, Cultural Insensitivity

Given the diverse society we live in, it is important for dental assistants to demonstrate understanding and tolerance. Cultural competence acknowledges and incorporates the importance of culture, the assessment of cross-cultural relations, awareness of dynamics resulting from cultural differences and the adaptation of services to meet culturally-unique circumstances.

Dental assistants must treat all patients with dignity and respect regardless of the patient’s values, culture, religious beliefs or sexual orientation.

We acknowledge the College of Physical Therapists of Alberta (operating as Physiotherapy Alberta – College and Association) for giving us permission to adapt their Therapeutic Relationships: Establishing and Maintaining Professional Boundaries publication for the use of dental assistants.