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Professional Boundaries: Where They Are and Why We Cross Them

EMT steals morphine. Firefighters caught in pornography scandal. Ambulance director fired after being charged with embezzlement.

Each day seems to bring a new set of headlines most of us wouldn’t want to make. And with every headline that portrays an emergency services professional in a tawdry light, the public loses confidence in all of us who wear an, EMS uniform. So we must ask ourselves: Does off-duty behavior affect our jobs? What are our roles and responsibilities as EMS professionals? What are the professional boundaries, and why do we cross them?

This topic recently caught my interest when a physician friend told me he was teaching a boundaries course. He explained that when physicians run afoul of their medical boards, they’re sometimes mandated to complete certain courses to get them back on the ethics highway. For physicians, the boundary crossings tend to center on injudicious prescribing of medications to themselves, family or friends, or inappropriate sexual relationships with patients. I soon discovered these courses also exist for nurses, who may find themselves crossing professional boundaries by becoming too close to patients or engaging in substance abuse.

So this begs the questions: Where do„EMS professionals turn to learn the scope of their professional responsibilities?

What Are Boundaries?

Professional boundaries exist for the protection of our patients, as well as for our own protection as health-care providers. They define the appropriate interaction between, EMS professionals and the patients we serve. Any behavior or interaction that damages the patient, the professional or the care given can be considered a boundary violation. Particular violations occur when there’s an exploitation or a victimization of a patient by an ,EMS professional. The damage done by boundary violations extends to marriages, families, communities and our profession in general.

Do we have explicit boundaries in„EMS? Actually, they did teach us about this in school, in the section titled Roles and Responsibilities. In our professional roles, the boundaries are based on The EMT Code of Ethics. In 1978, the National Association of Emergency Medical Technicians adopted the code of ethics written by Charles Gillespie, MD. Under the code, individual practitioners pledge to accept and fulfill their obligations to society, other medical professionals and the profession of, EMS, and to follow the ethical code that governs our practice. We pledge to conserve life and alleviate suffering, as well as to respect confidentiality and the law.

Then why are we seeing some horrific breaches of the ethical standards we swore to uphold? The answer is simple: Because our value system must be internalized, and because we — as individuals and as professionals — must demonstrate we understand the difference between right and wrong. Many of us learned right from wrong from our parents and religious teachings when we were young children. Others learned something was ˙off limits the hard way. Whatever the method, we must understand the difference between right and wrong, deep down inside ourselves.

Beyond the Code

Being a professional means having specialized expertise in a given area in which we maintain a high level of proficiency. It also means we accept a level of self-regulation and agree to live by rule-governed conduct. This means refraining from acts that violate the public trust. The following are recognized qualities of a professional:

Integrity: The single most important quality of a professional is integrity. It means complete and total honesty in all actions. It’s what the public expects of us: Our actions must be above reproach — whether we’re on duty or not. If your partner pockets a patient’s cash, that’s a boundary violation. If you keep it to yourself, that’s a boundary violation as well.

Empathy: Our ability to sense how another person thinks and feels, even though we can’t get inside their head, is another essential quality of being a professional. It means extending compassionate behavior toward all of our patients — even toward the intoxicated person who gets us out of bed at 3 a.m. because they have nowhere to go.

Self-motivation: The person who gets another roll of toilet paper before the old one runs out shows self-motivation. It means doing what needs to be done, whether it’s your responsibility or not. It’s an internal drive for excellence. We should finish tasks we start without constant supervision. We should have enthusiasm for learning and take advantage of learning opportunities — even if our services won’t pay for it.

Appearance/personal hygiene: Anyone who has shared the cab of an ambulance with a partner who forgot to use deodorant on a hot summer day will know the importance of hygiene. Looking professional — a neat uniform, shiny shoes and well-groomed hair and fingernails — is a significant part of being a professional. If you’re a volunteer awakened in the middle of the night, you can still pull on a jumpsuit and ball cap and look professional. Excessive cologne/perfume, jewelry and outlandish hairstyles have no place in our profession. We need to look like we’re ready for anything — because that’s what we may be doing.

Self-confidence: Not to be confused with ego, self-confidence involves an accurate assessment of your own strengths and weaknesses. It means knowing what you’re good at, and where you still need to do some work. It’s a willingness to admit your mistakes and to learn from them. A trust and reliance on your abilities is critical to top performance in„EMS. A difficult intubation or IV stick presents a challenge you must know you can meet.

Communication skills: Communication skills are essential. How does the physician see what we’re seeing? We must paint a picture with words and transmit that picture over the radio to the emergency department. Also, we must talk to our patients in a way that calms and reassures them, letting them know we’re there to help them. Good communication skills means active listening, and careful documentation and report writing. It means taking the time to write legibly and using the dictionary to learn the proper spelling of medical terminology. It also means having the ability to work with other public safety professionals in a way that fosters the best care for our patients.

Time management: EMTs don’t work in an office and may not understand time management in the context of what office managers do. But what happens if you’re 10 minutes late coming on shift? Inevitably, a call will come in right at shift change and the exhausted EMT from the previous shift will have to take that call, possibly ruining their first day off. Plan ahead: Get to work early so you can take that call and let the outgoing shift go home. Get your equipment check done at the beginning of the shift. Do your paperwork promptly. And don’t wait until the last month of your licensing cycle to think about getting in your continuing education requirements.

Teamwork: We often work with others toward a common goal, and not only with those wearing the same uniform. Disaster preparedness means getting ready to work with other services, and other public safety organizations, under adverse conditions. It means being open to change, finding creative solutions to difficult situations, and working with weaker members of the team to make them stronger. It means problem solving, not creating departmental disputes.

Respect: Deferential regard for others is another must. If you give it, you’ll most likely receive it in return. Showing respect — and not ostracizing those who aren’t exactly like us — allows for differences in a diverse EMS workplace. It means being polite, not using demeaning terminology, and bringing credit to your agency and your profession. Disrespectful behavior toward women, minorities or rookies on the emergency services team is immature and unprofessional.

Patient advocacy: The patient’s needs come first. If the EMT puts their needs before those of the patient, then a professional boundary is violated. Patient advocacy means accepting a patient who may have different values from yours and not imposing your belief system on your patient. We should take the time to make the world a better place for our patients and work toward a better„EMS response system in our communities. You may not get paid by the hour for your efforts, but the rewards will be with you for your entire career.

Careful delivery of service: Your responsibility is to follow policies and protocols. If your agency’s policies or protocols aren’t working, try to change them in a positive way. Use the equipment checklist every shift to identify possible equipment failures before they happen. Check your drug box for expired medications. Anticipate problems before they happen and take steps to avoid them. Drive carefully and safely to avoid being among the growing number of collisions and deaths. Keep your skills up and take the time to read the current medical literature to know what’s new or changing in our profession.

Boundary Crossings

Most of the aspects of being a professional seem apparent and indisputable, so what leaves us susceptible to crossing professional boundaries? Experts have identified three danger zones for boundary crossings: being tired, being seduced and being unprepared.

Being tired: Fatigue is a known precursor to all kinds of mishaps (see„JEMS March 2007 and„EMS Insider June 2006). From vehicle crashes to medication errors, fatigue has been identified as a major problem in the delivery of prehospital care, much as it has for pilots, truck drivers and medical residents. However, fatigue can also make us vulnerable to crossing professional boundaries.

Perhaps you’re working more than your regular shifts and have been taking on too much overtime just to pay the bills. Or maybe you’re a volunteer in a rural community, working a full-time job during the day and running calls on nights and weekends. Some of us work nights, and then don’t get a good night’s sleep during the day because of children or ringing telephones.

Whatever the cause of fatigue, we can find ourselves suddenly prone to making mistakes we wouldn’t make if we were well rested. Studies have shown that more patient refusals of transport (no loads) occur at the end of long shifts, and many„EMS vehicle collisions are believed to be the result of responders dozing off at the wheel due to exhaustion. You owe it to your patients — and to yourself and your family — to ensure you’re getting sufficient rest so your job performance doesn’t suffer.

Being seduced: Being seduced isn’t just about a sexual proposition from a too-young and attractive person. If we’re hungry, we can be seduced by food; if we’re broke, we can be seduced by money. An EMT with a gambling problem may be easily seduced by a patient’s wallet lying on the bedside table. When he loses his job because his partner turned him in, he’ll wonder what he was thinking when he took that money.

The exciting and seductive quality of the world of lights and sirens gives us the adrenaline rush we all know and love. But many of us have experienced the social isolation that results from shift work and from being part of the„EMS team. That isolation can lead to the seduction of drugs, alcohol and the problems that come with addictive behavior.

Being unprepared: EMTs and paramedics are often placed in situations for which they have no prior experience or training. Although we seem to do well finding creative solutions to unusual patient care and extrication problems, we falter when faced with issues that we haven’t had the opportunity to think through. When a patient asks us if we’ll hold onto their drug stash, we must have the presence of mind to decline.

Sometimes, unethical behavior starts off minor and then snowballs on us. For example, imagine personnel attending a party that starts to get wild. A young, obviously intoxicated woman begins to disrobe and shows off her new ˙jewelryÓ in the form of body piercings, to the delight of the other partygoers. Instead of helping her cover up and taking her home, the EMTs in the group stand back and say nothing. The next day, it turns out that she was underage and was raped outside the party.

Staying Out of Trouble

Can we predict boundary violations and learn how to stay out of trouble? Experts say we can look down the road and see trouble coming far enough ahead to avoid it. Signs of trouble are obvious if you’re looking for them. If you see people in your service who obviously live a lifestyle bigger than their paychecks, watch for problems ahead. People who amass large credit card debt, and live in houses and drive cars their salaries can’t justify, may be tempted to steal from patients — a clear boundary violation.

Immature sexuality is another predictor of trouble. EMT providers are in a position to view many unclothed bodies, and must always maintain a professional attitude and demeanor, no matter what they see. Putting 12-lead electrodes on a woman with large breasts is difficult for some, so talk about these issues during training and emphasize the need for discretion at all times when dealing with patients’ bodies. Further, the EMS station is no place for pornography of any kind. Videos, Internet sites and magazines depicting women and men as sexual objects are simply taboo in our workplace. Sexual encounters in the workplace are similarly an example of immature behavior.

Bad attitudes are often followed by bad actions, and some EMS personnel develop attitudes toward their employers that are less than professional. Providers who have a ˙take what you can get entitlement attitude are also heading for trouble. When we begin to put ourselves before anyone else, the groundwork for a boundary violation is being set.

Loneliness and isolation also predict boundary crossings. The EMT who’s not interacting with others in a healthy way may be heading for disaster. Depression isn’t uncommon among„EMS professionals, and feelings of isolation from the rest of the normal world can foster alienation. Substance abuse, also called ˙self-medication for depression, can follow. Those who always keep to themselves, don’t communicate or seem especially happy may secretly suffer from depression and be in line for difficult times.

Sensible Skills

Fortunately, you can develop the skills to keep yourself and those around you from crossing professional boundaries. Staying out of trouble is a matter of recognizing problems before it’s too late. An internalized value system is the most essential tool to use to avoid professional boundary violations. If it feels wrong, it probably is. Whether you get your value system from your parents, your religion or the ˙school of hard knocks, it’s important to know where your boundaries lie. Good family values, a caring and compassionate attitude, a true desire to serve the public, and a healthy lifestyle will go a long way to keep you within professional boundaries.

The benefit of a healthy lifestyle can’t be overstated. Regularly exercising, maintaining your ideal weight, eating a healthy diet and getting proper rest are all important to balancing our lives. Having interests outside of EMS also plays a big role. Whether you like coaching sports, engaging in woodworking or hiking, find something you enjoy that has nothing to do with EMS. Gardening or taking a walk on a sunny day will help keep your perspective straight and often make the horrors of your previous shift fade into the background.

Seek relationships with healthy people outside of the EMS team. Building loving relationships with friends, family and a life partner to share your trials and tribulations will also go a long way toward avoiding boundary violations. When you have a bad shift, share something fun with a child, and see the world through the eyes of a three year old. Enjoy a sense of belonging by making positive contributions to your community.

Steer away from the dark side of life and discover positive outlets for the inevitable stress of„EMS. Humor is a wonderful outlet for the pressure of our interactions, and the ability to laugh in the face of tragedy is healthy when it’s kept in the proper venue. Teaching new EMTs can also be highly rewarding for those of us who’ve had extensive field experience.

Take care of yourself. It’s the only way you can help others.


  1. ˙EMSCode of Ethics.Ó„
  2. Larkin GL, Fowler RL. ˙Essential ethics for„EMS: Cardinal virtues and core principles.Ó. Emergency Medicine Clinics of North America 2002;20:887-911.„
  3. Flores A.„Professional Ideals, Wadsworth Inc.; 1988.
  4. Caroline N. ˙Chapter 5.Ó.„Emergency Care in the Streets, Jones„& Bartlett; 2008.„
  5. Berry S.„