Journal of Psychosocial Nursing and Mental Health Services

CNE Article Supplemental Data

Professional Boundaries of Nursing Staff in Secure Mental Health Services: Impact of Interpersonal Style and Attitude Toward Coercion

Katie Lambert, MSc; Simon Chu, PhD, CPsychol, AFBPsS; Polly Turner, PhD, CPsychol

Abstract

The current study explored the impact of nursing staff members' interpersonal style and attitudes toward coercion on the management of their professional boundaries. Researchers predicted that a combination of a particular interpersonal style, a specific attitude toward coercion, and self-reported engagement in boundary-crossing behavior would be associated with particular styles of boundary management as outlined by Hamilton's Boundary Seesaw Model. Sixty-three nursing staff members in secure inpatient mental health services completed measures of boundary management, boundary crossings, attitude toward coercion, and interpersonal style. Regression analyses showed that a submissive interpersonal style and fewer boundary-crossing behaviors were associated with a pacifier boundary management style. In contrast, a pragmatic attitude toward coercion predicted a negotiator style of boundary management. The regression model for controller boundary management style was not significant. Findings are explored, along with their impact and implications for research and practice. [Journal of Psychosocial Nursing and Mental Health Services, 57(2), 16–24.]

Abstract

The current study explored the impact of nursing staff members' interpersonal style and attitudes toward coercion on the management of their professional boundaries. Researchers predicted that a combination of a particular interpersonal style, a specific attitude toward coercion, and self-reported engagement in boundary-crossing behavior would be associated with particular styles of boundary management as outlined by Hamilton's Boundary Seesaw Model. Sixty-three nursing staff members in secure inpatient mental health services completed measures of boundary management, boundary crossings, attitude toward coercion, and interpersonal style. Regression analyses showed that a submissive interpersonal style and fewer boundary-crossing behaviors were associated with a pacifier boundary management style. In contrast, a pragmatic attitude toward coercion predicted a negotiator style of boundary management. The regression model for controller boundary management style was not significant. Findings are explored, along with their impact and implications for research and practice. [Journal of Psychosocial Nursing and Mental Health Services, 57(2), 16–24.]

Clinicians practicing within secure services are required to balance the competing agendas of care and security. This balance involves promoting a therapeutic approach while also containing and safeguarding against risk, thus reflecting the dual (and sometimes competing) roles of clinicians working within forensic psychiatric settings (Hamilton, 2010). Relational security is one proposed way to balance these needs for the client. Relational security is a rich understanding of the client and his/her environment that can inform the care and management of that client. This thorough understanding of the client's needs and behavior, and a sound relationship with the client, can act as a form of security if the understanding is based on a professional, therapeutic, and purposeful relationship that is in line with professional boundaries (Department of Health, 2010).

Professional boundaries are the parameters that define appropriate behavior in a relationship with a client (Gutheil & Brodsky, 2008). Clinical practice should be monitored to safeguard against staff members and clients being exploited and to ensure that a balance between security and care is achieved. Consistent boundaries are needed within clinical relationships to provide the context for recovery (Moore, 2012). The literature explores how relationship boundaries may change and distinguishes between boundary movements that can contribute to a violation (Gutheil & Gabbard, 1993). Although clients may try to shift relational boundaries (e.g., through making inappropriate requests or asking personal questions of staff members), it is the responsibility of the clinician to appropriately manage his/her professional boundaries in line with guidance given within the professional codes of conduct and organizational policies (Gutheil & Brodsky, 2008).

Clinical policies often emphasize the role of a client's behavior to inform boundary management, whereas the clinician's role in the interaction has received little attention. The literature, on the other hand, emphasizes that the nature of the interaction should be considered in terms of both the client's and clinician's contributions (Daffern et al., 2010). Therefore, exploring the clinician's role in the interaction is pertinent when considering professional boundaries. Hamilton (2010) proposed the Boundary Seesaw Model, which proposes three main relational boundary management styles: controller, pacifier, and negotiator. The controller boundary management style is characterized by emotional distance, controlling behaviors, concern about risk management, and possible possession of negative views about the care and treatment of clients. Individuals with controller boundary management styles have rigid and inflexible boundaries. The pacifier boundary management style, however, reflects a placatory, overly accepting, self-sacrificing, emotionally close, and overly involved relational style focused on the client's needs. Pacifiers have flexible boundaries with a permissive view of risk. Finally, the negotiator boundary management style is characterized by a balance between containment and openness. Negotiators are responsive to the client's needs through flexible boundaries but have explicit limits. According to Hamilton (2010), the different boundary styles lie on a continuum, with the balanced negotiator boundary management style being optimal and lying between controller and pacifier boundary management styles. Boundary style may periodically shift (seesaw) to the controller or pacifier sides of the continuum and require rebalancing with appropriate boundary management. If boundaries are not managed and rebalanced, boundary violations could occur (Gutheil & Gabbard, 1993; Hamilton, 2010).

Some research has explored the vulnerabilities of clinicians that may contribute to the crossing of professional boundaries, such as insufficient training, inadequate practice, lapse of judgement, and social and cultural conditioning (Gutheil & Gabbard, 1993; Norris, Gutheil, & Strasburger, 2003). Hamilton (2010) also outlined how an individual's working style and professional conduct develops through his/her personal experiences, scripts, and beliefs. Daffern et al. (2010) support this finding, as they recommend that boundary styles with clients should fit with the interpersonal style of the client and interpersonal behavior of staff members. There is little empirical research on the interpersonal style of nursing staff members and its possible influence on boundary management because the focus has been on the client's boundary style within the interaction; however, interpersonal theory (Kiesler, 1983) can be applied to further understand the influence of staff interpersonal style.

Interpersonal theory considers an interaction between two individuals as a product of the characteristics that each individual brings to the interaction, and the reaction that each individual evokes in the other (Kiesler, 1983). This explanation of an interaction is known as the concept of complementarity. Complementarity is the extent to which the interacting individual styles “fit” with each other (Tracey, 2005), and how behaviors and non-verbal communication govern the exchanges within interactions (Carson, 1969; Kiesler, 1996; Sullivan, 1953). The theory suggests there are two core dimensions of interpersonal interactions that can influence the fit of styles: control, or dominance/submission, and affiliation, or friendliness/hostility (Leary, 1957). When positions of complementarity are being established, there may be a push and pull felt within the interaction.

Individuals seek to maneuver others to complement their own interpersonal style and reinforce the position they offer in the interaction (Kiesler & Auerbach, 2003). For instance, friendliness pulls for friendliness and hostility pulls for hostility on the affiliation dimension, whereas on the control dimension, dominance pulls for submission and submission pulls for dominance. If the complementary reaction is not elicited during the interaction, an individual's anxiety level may increase and subsequently influence the interaction (Daffern et al., 2010; Tracey, 2005). In forensic populations, studies have found that clients are commonly characterized by a hostile, hostile–dominant, or dominant interpersonal style (Daffern et al., 2010). For instance, if a client within a forensic setting presents with a hostile interpersonal style, it may result in hostility from nursing staff members. If the nurse does not respond in a hostile manner, this response will conflict with the client's expectations of reciprocated hostility. This inconsistency in expectations may increase anxiety within the client, who may then escalate his/her behavior to increase the pull for hostility from staff members. Therefore, it is important for staff members to acknowledge the impact of clients' interpersonal style and how it may influence their reactions (Daffern, Day, & Cookson, 2012).

Daffern et al. (2010) found that nursing staff members' reaction to an interaction is driven by their preferred interpersonal style, suggesting, for example, that a client's dominant–hostile interpersonal style may elicit a passive response from staff members with a submissive interpersonal style, but hostility from staff members with a dominant interpersonal style. Research has found that when nursing staff members responded to hostility with a dominant response (e.g., intimidation, restraint, seclusion), the response appeared to be due to staff members' perceived loss of power or limited self-efficacy to manage the situation (Drach-Zahavy, Goldblatt, Granot, Hirschmann, & Kostintski, 2012). This dominant approach may indicate an attitude supportive of coercion (i.e., acceptance of using enforcement and control, rather than persuasion, as a means of influencing client behavior). In addition, Daffern, Howells, and Ogloff (2006) found that dominant behaviors from staff members, such as demands for client activity or denial of client requests, preceded acts of aggression in secure psychiatric services. The evidence suggests that pro-coercion attitudes may be associated with a dominant interpersonal style and may potentially shift an individual's boundary management style to the controller side of the Boundary Seesaw Model (Hamilton, 2010). The implications of these findings are pertinent in that staff members' interpersonal style and attitude toward coercion could influence their professional boundaries. Limited research exists on the submissive interpersonal style of nursing staff members, but due to the characteristics of the style, it could be hypothesized that this style is linked to permissive behavior, an anti-coercion attitude (i.e., an attitude that coercion is harmful to clients), and a shift toward the pacifier side of the Boundary Seesaw Model (Hamilton, 2010).

The concept of interpersonal rigidity can further aid the understanding of shifts in professional boundaries. Interpersonal rigidity is an inability to adapt one's behavior in different situations or an overuse of one set of behaviors, regardless of the situation or social norms (Tracey, 2005). In interpersonal situations, individuals with a rigid interpersonal style may act in a narrow range of behavior and struggle to adapt their behavior to that of other individuals within the interaction. Thus, complementarity may be low and productivity of the relationship may be jeopardized. The opposite of rigidity is flexibility, which, in terms of interpersonal behavior, may reflect the negotiator boundary management style. Individuals who adopt this balanced and flexible style may adapt to the context and situation to manage relationships more effectively without engaging in any boundary shifts.

As noted previously, nursing staff members are responsible for holding their professional boundaries in line with organizational policy and professional regulatory bodies; thus, it would be valuable to understand the impact of interpersonal style on boundary management. The current study aims to explore the influence that two core factors, interpersonal style and attitude toward coercion, have on the management of nursing staff members' professional boundaries within secure psychiatric care. The following core predictions are made:

  • A dominant interpersonal style, an attitude that coercive behavior is justified (pro-coercion), and engagement in boundary shift behaviors will predict the controller boundary management style.
  • A submissive interpersonal style, an attitude that coercion is harmful (anti-coercion), and engagement in boundary shift behaviors will predict the pacifier boundary management style.
  • A friendly (pro-social), adaptive interpersonal style, a pragmatic attitude toward coercion (according to treatment need), and limited engagement in boundary shift behaviors will predict the negotiator boundary management style.

Method

Design and Participants

A within-participant design examined the relationship between nursing staff members' boundary management style and their interpersonal style, attitude toward coercion, and engagement in boundary-crossing behaviors. Sixty-three participants completed the study, 34 men and 29 women between ages 26 and 63 (mean age = 48.4 years, SD = 8 years). Participants were nursing staff members at a mental health trust in northwest England that operated high secure, medium secure, and low secure forensic mental health units, as well as community mental health services. All participants were recruited via internal e-mail. This e-mail contained information regarding the study and a URL to a questionnaire hosted on a secure online survey site. Sixty-one percent of the sample worked in high secure, 32% in medium secure, and 7% in low secure services.

Materials

The Staff Attitude to Coercion Scale (SACS; Husum, Finset, & Ruud, 2008) explored staff members' views of coercion in three different areas: coercion as a treatment need (coercion is justified; pro-coercion); coercion as harmful to the client (coercion is not justified; anti-coercion); and coercion to ensure security and care (coercion-pragmatic). The measure comprised 15 items scored on a 5-point Likert scale ranging from strongly disagree to strongly agree, with higher scores indicating more agreement with an item. The measure has medium to high reliability (Cronbach's alpha = 0.78), with reliability of subscales ranging from 0.69 to 0.73 (Husum et al., 2008).

Inventory of Interpersonal Problems (IIP-32; Horowitz, Alden, Wiggins, & Pincus, 2000) explores an individual's most salient interpersonal difficulties based on the interpersonal control and affiliation circumplex. Subscales include domineering/controlling, self-centered, cold/distant, socially inhibited, non-assertive, overly accommodating, self-sacrificing, and intrusive/needy. Low scores within these areas indicate a friendly, pro-social, and optimal interpersonal style. Each of the 32 items is rated on a 5-point Likert scale from not at all to extremely, which reflects how hard the participant finds it to participate in activities with others. The measure has high reliability (Cronbach's alpha = 0.93), with subscales ranging from medium to high reliability (Cronbach's alpha = 0.68 to 0.87) (Horowitz et al., 2000). Because of issues related to statistical power, the subscales could not be used individually; therefore, they were summed to create two subscales: a dominant and submissive interpersonal style. The higher the score, the stronger the interpersonal style. These subscales were reversed and summated to generate a score for a prosocial and adaptive interpersonal style. The higher the score on this scale, the more healthy, warm, and assertive the interpersonal style to be able to connect and interact appropriately with others.

Boundary management vignettes were created based on the Boundary Seesaw Model styles of controller, negotiator, or pacifier (Hamilton, 2010). Participants were asked to read six vignettes (Table A, available in the online version of this article), where each vignette presented a situation with a client where a boundary violation could occur. Each vignette also presented three alternative responses that mapped onto the three boundary management styles. Participants were asked to rate how much they agreed with each response to the vignette on a 7-point Likert scale ranging from strongly agree to strongly disagree. The first author (K.L.) completed a small pilot study (n = 7) trialing the vignettes to ensure consistency and face validity. Ultimately, all scores for each of the three types of response (controller, negotiator, and pacifier) may be summated to produce an overall score for the subscale, with a higher score reflecting more agreement with that approach to boundary management.

An example of a vignette measuring boundary management style

Table A:

An example of a vignette measuring boundary management style

A 23-item self-report list of boundary-crossing behaviors was constructed based on behaviors outlined within practice that were deemed a boundary crossing (Table B, available in the online version of this article). The information regarding practice-based crossings was gathered from discussions with clinical staff members and from the training package on the management of professional boundaries. Participants were asked to indicate whether they had engaged in any of the behaviors using a 5-point Likert scale ranging from not at all to usually/frequently. The responses were summated to produce an overall score, with higher total scores indicating more frequent engagement in behaviors associated with boundary crossings.

Boundary Crossing Behaviours Checklist

Table B:

Boundary Crossing Behaviours Checklist

Procedure

The current study was granted ethical approval by the Research Ethics Committee at the University of Central Lancashire. Participants were selected for the study if they were ward-based health care assistants or nurses and were recruited via internal e-mail. Within the e-mail, participants were informed about the study and provided with a link to an online questionnaire. The online questionnaire contained information regarding the study via an information sheet to enable participants to provide informed consent. As the study was online, participants were asked to check a box to confirm they understood several statements to ensure consent was provided. Within the information sheet, participants were informed about confidentiality and their right to withdraw. Participants were then directed to complete the four measures and were debriefed after completion.

Results

Data were screened for missing values, normality, and the necessary parametric assumptions. Missing values were addressed via mean replacement, which was calculated using the appropriate subscale to represent the concept the missing item intended to measure. The data had a non-normal distribution and log transformations were explored in attempt to increase normality. Although normality was improved, the results did not alter. Researchers decided to use the original data for analysis to avoid potentially changing concepts explored through transformation of the data (Tabachnick & Fidell, 2014). The means and standard deviations for each variable were explored (Table 1).

Mean, Standard Deviation, and Minimum and Maximum Scores for the Overall Sample and Measure Subscales

Table 1:

Mean, Standard Deviation, and Minimum and Maximum Scores for the Overall Sample and Measure Subscales

From exploration of the means, the predominant attitude toward coercion for the group overall was coercion-pragmatic (i.e., a pragmatic attitude that coercion is needed for care and security). The interpersonal style subscales suggested the group had higher submissive interpersonal style, and the boundary management style subscales indicated a group preference for negotiator boundary management style.

Table 2 shows the correlational relationships between variables. There were significant relationships between the criterion variable of boundary management style and the predictor variables. The controller boundary management style was positively correlated with a pro-coercion attitude as well as the pacifier boundary management style. The negotiator boundary management style was positively correlated with a coercion-pragmatic attitude, an anti-coercion attitude, and boundary-crossing behaviors. A pacifier boundary management style was positively correlated with a pro-coercion attitude and submissive interpersonal style, and negatively correlated with boundary-crossing behaviors. Significant positive relationships were also found between boundary-crossing behaviors and anti-coercion and coercion-pragmatic attitudes. In addition, the dominant, submissive, and pro-social interpersonal styles all correlated significantly with each other.

Pearson's r Correlation Matrix Demonstrating the Relationship Between Nursing Staff's Boundary Management Style, Interpersonal Style, Attitude Toward Coercion, and Engagement in Boundary-Crossing Behaviors

Table 2:

Pearson's r Correlation Matrix Demonstrating the Relationship Between Nursing Staff's Boundary Management Style, Interpersonal Style, Attitude Toward Coercion, and Engagement in Boundary-Crossing Behaviors

In line with a theory-driven approach, analysis was conducted on variables expected to have a relationship within the theory. Three simultaneous multiple entry regression analyses were conducted to explore the relative contribution and independent associations of the predictor variables of interpersonal style, attitude toward coercion, and engagement in boundary-crossing behaviors on an individual's boundary management style.

Controller Boundary Management Style

The model of controller boundary management style as predicted by dominant interpersonal style, pro-coercion attitudes, and engagement in boundary-crossing behaviors was not significant (Table 3) (F (3, 59) = 1.94, mean standard error [MSE] = 3.81, p = 0.13). None of the predictors within the model individually significantly predicted a controller boundary management style.

Linear Model of Predictors of Controller Boundary Management Style (N = 63)

Table 3:

Linear Model of Predictors of Controller Boundary Management Style (N = 63)

Pacifier Boundary Management Style

The model of the pacifier boundary management style as predicted by submissive interpersonal style, anti-coercion attitudes, and engagement in boundary-crossing behaviors was significant (Table 4) (F (3, 59) = 2.73, MSE = 3.86, p = 0.05). The predictors together explained 12% of variance in the pacifier boundary management style scores. A significant contribution was made to the model by submissive interpersonal style (t = 2.30, p = 0.02, ß = 0.29), suggesting that an increase in this predictor by one standard deviation would result in an increase in pacifier boundary management style scores by 29% of one standard deviation. Boundary-crossing behavior also significantly predicted a pacifier boundary management style (t = −2.11, p = 0.03, ß = −0.27), suggesting that an increase in this predictor by one standard deviation would result in a reduction in pacifier boundary management style scores by 27% of one standard deviation. An attitude that coercion is harmful was not independently associated (t = 0.41, p = 0.64, ß = 0.06).

Linear Model of Predictors of Pacifier Boundary Management Style (N = 63)

Table 4:

Linear Model of Predictors of Pacifier Boundary Management Style (N = 63)

Negotiator Boundary Management Style

The model of negotiator boundary management style as predicted by pro-social interpersonal style, a coercion-pragmatic attitude, and engagement in boundary-crossing behaviors was significant (Table 5) (F (3, 59) = 3.43, MSE = 4.06, p = 0.02). The predictors together explained 15% of variance in the negotiator boundary management style scores. A significant contribution was made to the model by coercion-pragmatic attitudes (t = 2.62, p = 0.01, ß = 0.33), suggesting that an increase in this predictor by one standard deviation would result in an increase in negotiator boundary management style scores by 33% of one standard deviation. A pro-social interpersonal style (t = −0.13, p = 0.88, ß = −0.02) and boundary-crossing behavior (t = 1.04, p = 0.32, ß = 0.13) were not independently associated.

Linear Model of Predictors of Negotiator Boundary Management Style (N = 63)

Table 5:

Linear Model of Predictors of Negotiator Boundary Management Style (N = 63)

Discussion

The study aimed to explore, among nursing staff members within secure mental health services, whether an individual's interpersonal style, attitude toward coercion, and engagement in self-reported boundary-crossing behaviors affected their boundary management style. The models for pacifier and negotiator boundary management styles were significant, whereas these factors were not found to significantly influence the model for controller boundary management style.

Scores for the controller boundary management style were not predicted by dominant interpersonal style, pro-coercion attitudes, and engagement in boundary-crossing behaviors; thus, these findings do not provide support for the theory and literature suggesting a relationship between these variables (Daffern et al., 2006; Drach-Zahavy et al., 2012; Hamilton, 2010; Kiesler, 1983). Dominant interpersonal style and boundary-crossing behaviors were self-reported within the overall sample, yet no relationships were found in relation to a controller boundary management style. Interestingly, the greater the controller boundary management style, the stronger the pro-coercion attitude. H owever, this relationship was non-significant within the regression model. It is therefore suggested that these factors cannot adequately explain this boundary management approach and there may be other factors that drive a controller boundary management style that are not captured in this model (Gutheil & Gabbard, 1993; Norris et al., 2003).

Noteworthy is the finding that the controller boundary management style positively correlated with the pacifier boundary management style. This finding supports Hamilton's (2010) Boundary Seesaw Model because both styles represent difficulties in maintaining boundaries. This relationship could potentially reflect a tendency for nursing staff members to switch between controlling and permissive styles of boundary management.

The hypothesis that a submissive interpersonal style, anti-coercion attitude, and engagement in boundary-crossing behaviors would predict pacifier boundary management style scores was supported by the data. Submissive interpersonal style and engagement in boundary-crossing behaviors were both significant predictors within the model. This finding contributes new information to the evidence base. Considering studies finding that clients in secure care tend to have a hostile–dominant interpersonal style (Daffern et al., 2010) and the notion of complementarity within interpersonal theory, it may be that there is a pull for submission from nursing staff members during interaction with clients (Kiesler, 1983, 1996; Kiesler & Auerbach, 2003). As Daffern et al. (2012) noted, it is important for staff members to acknowledge the impact of a client's interpersonal style on staff members' own reactions. It is therefore of clinical importance that staff members are aware of whether they have submissive interpersonal styles so they are not too permissive in their boundary management style. This awareness is especially important if there is interpersonal rigidity within nursing staff members' or their clients' interpersonal styles, as rigidity could result in boundary violations (Hamilton, 2010; Tracey, 2005) and ineffective relational security (Department of Health, 2010).

Contrary to expectations, the findings indicated that the greater the pacifier boundary management style, the greater the pro-coercion attitude, rather than anti-coercion attitude as was predicted. A potential explanation of this finding is that individuals with a submissive interpersonal style and boundary-crossing behaviors who engage in a pacifier management style may experience a loss of control and power. With this loss of control, staff members may need to resort to coercion to manage the situation and reinstate their professional boundaries (Drach-Zahavy et al., 2012). Thus, nursing staff members with a pacifier boundary management style may potentially be forced to switch to a controller boundary management style in such instances, and it is noteworthy that there was a positive relationship between scores on the controller and pacifier boundary management styles. This explanation is speculative, but if correct, the implications for clinical practice are important in terms of nursing staff members' boundary management, their promotion of therapeutic relationships and recovery with clients, and potential negative cultural working systems.

The findings suggest that a pro-social interpersonal style, a coercion-pragmatic attitude, and engagement in boundary-crossing behaviors predict scores on the negotiator boundary management style. However, it is noteworthy that the only significant predictor in the model was a coercion-pragmatic attitude, which is an attitude consistent with the negotiator boundary management style. In this instance, interpersonal style of the individual staff member is less important than his/her attitude that care and security should be balanced through promoting a therapeutic approach with limits, which is reflective of the dual approach to care within secure services (Hamilton, 2010).

Overall, findings suggest that interpersonal style and attitude toward coercion may influence use of pacifier and negotiator boundary management styles. However, it is important to note that other factors may contribute to these relationships, as the factors examined did not fully explain all relationships within the model, and additional relationships were found regardless of boundary management style. For instance, boundary-crossing behaviors were related to an increase in submissive and pro-social interpersonal styles, coercion-pragmatic attitudes, and anti-coercion attitudes. The evidence base suggests other individual factors within nursing staff members may influence the nature of their interactions and professional boundaries with clients, including internal factors such as their personal experiences, scripts, and beliefs (Daffern et al., 2010; Hamilton, 2010), and external factors such as inadequate training or social and cultural factors (Gutheil & Gabbard, 1993; Norris et al., 2003). Thus, interpersonal style, attitudes toward coercion, and boundary-crossing behaviors, as indicated by theory, go only so far in explaining boundary management styles. Further exploration of individual factors would extend understanding of professional boundary management.

Limitations and Future Research

A potential limitation of the study is the methods used to test the concepts of boundary management styles and boundary-crossing behaviors. The boundary management style vignettes were trialed within the research team and the boundary-crossing behavior checklist was made in partnership with the clinical lead regarding practice-based evidence within the mental health trust. However, they are not validated measures. Thus, it may be that the boundary management constructs and boundary-crossing behaviors are not adequately represented. In addition, the limited sample size recruited may have affected the relationships found. Although there was adequate power for the calculations (power = 0.7), there was still a 30% chance of missing an effect between variables. Furthermore, due to limits in normality, the findings cannot be generalized to the wider nursing population; however, future research with an increased sample size and refined methodology may produce more generalizable results. In addition, exploration of other relevant and contributing factors could further increase understanding of the model.

Conclusion

The current study has shown that interpersonal style is a significant driver of the way in which nursing staff members manage professional boundaries with clients, and staff members would benefit from an awareness of how their own interpersonal styles influence their clinical practice. It is clear from the data that a submissive interpersonal style is strongly linked to permissive boundary management, and staff with a submissive interpersonal style should be particularly aware of maintaining appropriate boundaries. The data also suggest that the controller and pacifier boundary management styles appear to go hand in hand, and some staff members may seesaw between two approaches depending on their level of control. An awareness of this possibility may promote the likelihood of a more consciously considered and consistent approach in handling boundaries with clients. The data also suggest that the main driver for the negotiator boundary management style is the presence of a pragmatic attitude to coercive practice (i.e., a pragmatic view that coercion [and restrictive practice] are neither positive nor desirable, but are sometimes necessary to maintain safety and security). However, attitudes are malleable, and given that the negotiator boundary management style is viewed as the optimal approach to boundary management, staff training to develop and inspire more coercion-pragmatic attitudes may be beneficial to the development of healthier boundary management styles in staff members.

References

  • Carson, R.C. (1969). Interaction concepts of personality. Chicago, IL: Aldine.
  • Daffern, M., Day, A. & Cookson, A. (2012). Implications for the prevention of aggressive behavior within psychiatric hospitals drawn from interpersonal communication theory. International Journal of Offender Therapy and Comparative Criminology, 56, 401–419. doi:10.1177/0306624X11404183 [CrossRef]
  • Daffern, M., Howells, K. & Ogloff, J. (2006). What's the point? Towards a methodology for assessing the function of psychiatric inpatient aggression. Behaviour Research and Therapy, 45, 101–111. doi:10.1016/j.brat.2006.01.011 [CrossRef]
  • Daffern, M., Thomas, S., Ferguson, M., Podubinski, T., Hollander, Y., Kulkhani, J. & Foley, F. (2010). The impact of psychiatric symptoms, interpersonal style, and coercion on aggression and self-harm during psychiatric hospitalization. Psychiatry, 73, 365–381. doi:10.1521/psyc.2010.73.4.365 [CrossRef]
  • Department of Health. (2010). Your guide to relational security: See, think, act. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/320249/See_Think_Act_2010.pdf
  • Drach-Zahavy, A., Goldblatt, H., Granot, M., Hirschmann, S. & Kostintski, H. (2012). Control: Patients' aggression in psychiatric settings. Qualitative Health Research, 22, 43–53. doi:10.1177/1049732311414730 [CrossRef]
  • Gutheil, T.G. & Brodsky, A. (2008). Preventing boundary violations in clinical practice. New York, NY: Guilford.
  • Gutheil, T.G. & Gabbard, G.O. (1993). The concept of boundaries in clinical practice: Theoretical and risk management dimensions. American Journal of Psychiatry, 150, 188–196. doi:10.1176/ajp.150.2.188 [CrossRef]
  • Hamilton, L. (2010). The boundary seesaw model: Good fences make for good neighbours. In Tennett, A. & Howells, K. (Eds.), Using time, not doing time: Practitioner perspectives on personality disorder and risk (pp. 181–194). West Sussex, UK: John Wiley & Sons. doi:10.1002/9780470710647.ch13 [CrossRef]
  • Horowitz, L.M., Alden, L.E., Wiggins, J.S. & Pincus, A.L. (2000). Inventory of interpersonal problems manual. San Antonio, TX: Psychological Corporation.
  • Husum, T.L., Finset, A. & Ruud, T. (2008). The Staff Attitude to Coercion Scale (SACS): Reliability, validity and feasibility. International Journal of Law and Psychiatry, 31, 417–422. doi:10.1016/j.ijlp.2008.08.002 [CrossRef]
  • Kiesler, D.J. (1983). The 1982 interpersonal circle: A taxonomy for complementarity in human transactions. Psychological Review, 90, 185–214. doi:10.1037/0033-295X.90.3.185 [CrossRef]
  • Kiesler, D.J. (1996). Contemporary interpersonal theory and research: Personality, psychopathology and psychotherapy. New York, NY: Wiley.
  • Kiesler, D.J. & Auerbach, S.M. (2003). Integrating measurement of control and affiliation in studies of physician-patient interaction: The interpersonal circumplex. Social Science & Medicine, 57, 1707–1722. doi:10.1016/S0277-9536(02)00558-0 [CrossRef]
  • Leary, T. (1957). Interpersonal diagnosis of personality: A functional theory and methodology for personality evaluation. New York, NY: Ronald Press.
  • Moore, E. (2012). Personality disorder: Its impact on staff and the role of supervision. Advances in Psychiatric Treatment, 18, 44–55. doi:10.1192/apt.bp.107.004754 [CrossRef]
  • Norris, D.M., Gutheil, T.G. & Strasburger, L.H. (2003). This couldn't happen to me: Boundary problems and sexual misconduct in the psychotherapy relationship. Psychiatric Services, 54, 517–522. doi:10.1176/appi.ps.54.4.517 [CrossRef]
  • Sullivan, H.S. (1953). The interpersonal theory of psychiatry. New York, NY: Norton.
  • Tabachnick, B.G. & Fidell, L.S. (2014). Using multivariate statistics (6th ed.). Essex County, UK: Pearson.
  • Tracey, T.J.G. (2005). Interpersonal rigidity and complementarity. Journal of Research in Personality, 39, 592–614. doi:10.1016/j.jrp.2004.12.001 [CrossRef]

Mean, Standard Deviation, and Minimum and Maximum Scores for the Overall Sample and Measure Subscales

SubscaleMean (SD)Range of Study SampleMinimum and Maximum Scores for the Subscale
Staff Attitude to Coercion Scale
  Coercion is harmful to the client17.95 (3.56)11 to 256 to 30
  Coercion is justified8.29 (2.75)3 to 153 to 15
  Coercion is pragmatic19.91 (4.93)7 to 296 to 30
Inventory of Interpersonal Problems-32
  Dominant interpersonal style18.30 (7.43)12 to 385 to 60
  Submissive interpersonal style37.10 (11.09)21 to 6620 to 100
  Pro-social interpersonal style69.14 (19.71)18 to 9532 to 160
  Boundary-crossing behavior32.31 (5.68)23 to 4623 to 115
  Pacifier management style11.33 (4.02)6 to 226 to 42
  Controller management style25.70 (3.89)18 to 356 to 42
  Negotiator management style33.55 (4.30)25 to 426 to 42

Pearson's r Correlation Matrix Demonstrating the Relationship Between Nursing Staff's Boundary Management Style, Interpersonal Style, Attitude Toward Coercion, and Engagement in Boundary-Crossing Behaviors

Boundary Management StyleNegotiator StylePacifier StyleAnti-Coercion AttitudePro-Coercion AttitudeCoercion-Pragmatic AttitudeBoundary-Crossing BehaviorDominant Interpersonal StyleSubmissive Interpersonal StylePro-Social Interpersonal Style
Controller style−0.138−0.326**−0.1190.253*0.106−0.0170.1740.145−0.150
Negotiator style−0.1230.212*0.1850.363**0.207*−0.0160.165−0.105
Pacifier style−0.0110.394**0.180−0.205*0.2040.236*−0.230*
Anti-coercion0.034−0.1160.233*−0.108−0.0010.52
Pro-coercion0.648**0.1370.1120.042−0.065
Coercion-pragmatic0.229*0.1720.176−0.205
Boundary-crossing behavior0.1100.182−0.162
Dominant interpersonal style0.596**−0.854**
Submissive interpersonal style−0.917**

Linear Model of Predictors of Controller Boundary Management Style (N = 63)

Variableb [95% CI]SE Bßp Value
Dominant interpersonal style0.81 [−0.05, 0.21]0.070.150.23
Pro-coercion attitude0.35 [−0.01, 0.70]0.180.240.06
Boundary-crossing behaviors−0.05 [−0.22, 0.13]0.09−0.070.60

Linear Model of Predictors of Pacifier Boundary Management Style (N = 63)

Variableb [95% CI]SE Bßp Value
Submissive interpersonal style0.10 [0.01, 0.19]0.050.290.02*
Anti-coercion attitude0.06 [−0.23, 0.34]0.140.060.64
Boundary-crossing behaviors−0.19 [−0.37, −0.01]0.09−0.270.03*

Linear Model of Predictors of Negotiator Boundary Management Style (N = 63)

Variableb [95% CI]SE Bßp Value
Pro-social interpersonal style0 [−0.07, 0.06]0.03−0.020.88
Coercion-pragmatic attitude0.28 [0.07, 0.51]0.110.330.01*
Boundary-crossing behaviors0.10 [−0.09, 0.29]0.100.130.32

An example of a vignette measuring boundary management style

A service user approaches you and asks if you have time to talk about something that is bothering them. You have a somewhat limited relationship with the service user but have had supportive conversations in the past. The service user lets you know that they feel that you understand them because you listen to them. They want to discuss something that is bothering them at the moment but does not want everyone knowing about their business. They feel that everyone knows everything about them and you empathise with this due to the environment they are in. They ask you to not let other staff members know about how they are feeling as everyone will then know their business and because they don't understand them like you do they will see it differently. What do you think of each of these possible responses? A. You view not telling other staff members information as being against procedure so you let the service user know that you don't have time to talk as you have a ward task to complete.
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Strongly DisagreeDisagreeMildly Disagree50/50Mildly AgreeAgreeStrongly Agree
B. You think that it is very positive that the service user feels that you understand them and so you explore what is bothering them but only after you make it clear that you must pass on any relevant information that they disclose.
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Strongly DisagreeDisagreeMildly Disagree50/50Mildly AgreeAgreeStrongly Agree
C. You think that it is good that the service user feels heard by you. You agree to listen to what they have to say and keep it confidential. In showing you understand them this may help to develop the trust in your relationship so you can continue to support them.
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Strongly DisagreeDisagreeMildly Disagree50/50Mildly AgreeAgreeStrongly Agree

Boundary Crossing Behaviours Checklist

Please read each item and note how frequently you have engaged in this behaviour in the past 6 months. Remember there are no right or wrong answers and your answers can not be identified to you so please be honest.

1 = Not at all

2 = Occasionally

3 = Sometimes

4 = Fairly Often

5 = Usually or Frequently

Kept something private that the service user asked you to

Shared personal or work information with a service user that is not to do with their care

Felt defensive of a service user

Talked about what you did at the weekend in ear shot of service users

Avoided interactions with a service users

Allowed a service user to do things differently to ward rules

Given an item to service user that they weren't supposed to have

Agreed with the positive comments a service user has made about staff

Interactions with service users have contained sexual innuendos

Spent your time with the service users you get on best with

Thought about service users away from work

Trusted certain service users more than others

Felt responsible if a service user's progress was limited

Disrespected others whilst talking to a service user

Swapped tasks to work with a service user you get on well with

Reported only certain aspects of the service user's behaviour whether it be positive or negative behaviours

Received gifts from a service user

Kept discussion and actions superficial with a service user

Noticed more physical touch with a service user than usual

Agreed with the negative comments a service user has made about others

You have brought treats in for a service user

Swapped tasks so you did not have to complete a task with a certain service user

Using your status as a staff member to manage a situation with a service user

Authors

Ms. Lambert is Forensic Psychologist in Training, and Dr. Chu is Research Fellow, School of Psychology, University of Central Lancashire, Preston, and Ashworth Research Centre, Ashworth Hospital, Mersey Care NHS Foundation Trust, Maghull; and Dr. Turner is Registered Forensic Psychologist, Division of Psychology and Mental Health, University of Manchester, Manchester, United Kingdom.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Simon Chu, PhD, CPsychol, AFBPsS, Research Fellow, School of Psychology, University of Central Lancashire, Preston, PRI 2HE, United Kingdom; e-mail: schu@uclan.ac.uk.

Received: May 11, 2018
Accepted: July 23, 2018
Posted Online: October 01, 2018

10.3928/02793695-20180920-05

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