Vol. 6 Issue 12
How nurses set professional boundaries to provide security, order and safe connections in patient interactions
In any healthcare interaction, individuals use expert knowledge to engage in purposeful relationships focused on meeting clients' needs within well-defined boundaries. This interaction becomes relevant and important, since the essence of nursing practice makes it possible for nurses to become significant people in patients' lives.
Nurses face many complexities in their relationships with patients, including the intimacy of caring actions, potential for long-term relationships, and care provided in less structured arenas during home care visits. This is even more significant with psychiatric nurses working with patients who experience a deviation in their mental health.
Although the nursing profession recognizes that each nurse-patient relationship is unique, as a healthcare professional, the nurse must strive to maintain professional interactions that will negate role confusion and boundary crossing.
What is the nature of the professional relationship? How can nurses recognize potential problem situations? What are some strategies for managing professional boundaries?
What Are Professional Boundaries?
The term professional boundaries identifies a range of specific and abstract concepts that tend to define where we can go, who we are, and what we can or should do as RNs. Furthermore, these boundaries separate therapeutic behavior of the registered nurse from any behavior that, well intentioned or not, could diminish the benefit of care to patients, families and communities.
Professional boundaries provide security, order and safe connections based on patient need. They are limits that protect the space between the professional's power and the patient's vulnerability in a therapeutic relationship, thereby defining the roles and responsibilities between people. The underlying concepts of boundaries are: power, choice and trust.
Power Within this nurse-patient relationship there is an inherent power imbalance, even in the case of a novice nurse and a veteran patient. The power of the nurse arises from her professional position being privy to knowledge, information and influence regarding the patient and care received.
This power imbalance is not dependent on the intelligence, education or confidence of the patient. It originates from the patient sharing personal information that is not normally communicated and is not reciprocated.
It is also a relationship of necessity, not choice. Nurses have close physical contact required for professional interventions based solely on their position, thus making the relationship one-sided. Ultimately, relationships with patients have the power to heal and to harm.
Establishing boundaries enables the nurse to control this power differential, thereby facilitating safe connections to meet the patients' needs. In assessing this, the nurse should ask herself: Is any of the patient's information used or shared inappropriately to the advantage of the nurse? Can the patient make well-informed decisions having full information without inappropriate influence from the nurse?
Choice Nurses should provide information in a timely manner to aid patients or their representative to make informed decisions when planning care. As such, nurses promote and respect the autonomy of patients and assist them with communicating their health needs and values.
Trust The importance of the trust inherent in the therapeutic relationship between nurses and patient is predicated on the nurse's knowledge, attributes and skills. The patient entrusts his care to a licensed professional who has unique knowledge in healthcare delivery to meet the patient's needs. Although vulnerability exists for the patient, nurses promote trust within the relationship by clearly communicating with patients and displaying professional behaviors. Professional boundaries are interpersonal in their construction and for many nurses represent sources of unremitting contention and reflection as they seek to do good for the patient and at the same time not cause harm.
Potential Problem Situations
Breaching of Boundaries Breaching of professional boundaries is going outside the limits of the therapeutic relationship. Healthcare professionals must maintain boundaries between themselves and their patients. This balancing act of maintaining boundaries in professional relationships comes with the responsibility and privilege of licensure and professional status.
Breach of these boundaries may range from mild to severe and typically inadvertent, subtle in nature and unconscious. These breaches may occur when establishing an economic, social and/or personal relationship with the patient. Examples include giving and receiving gifts; flirtations and/or sexual relationships with patients; and excessive self-disclosure.
It is imperative that RNs maintain an awareness of factors that increase the likelihood of their breaching professional boundaries. These include stressors in the nurse's personal life; drug and/or alcohol abuse; breakdown of personal relationships, mental illness and professional isolation.
Over-involvement with patients decreases the nurse's objectivity with interventions and patient treatment. Furthermore, once boundaries have been breached other factors must be considered: It is difficult to return to the "original" relationship; it may impair clinical judgment; it may facilitate further reciprocal intrusions and obligations as well as other serious violations.
Strategies for Managing Boundaries
Self-Awareness and Warning Signs The challenge for professionals is to be aware of their own behaviors that may lead to breaching of professional boundaries. Nurses are encouraged to reflect on their own behaviors and that of their colleagues and recognize the warning signs of potential breaches. Introspection is critical in the development of self-understanding, which involves objectively surveying one's strengths, attitudes, personal beliefs, motivations and limitations. There are clues that should be considered as warning signs and questions to recognize when reviewing potential boundary issues.
• Frequent thinking of the patient while away from work;
• Socializing with the patient outside of working hours;
• Planning the care of other patients around the "special" patient;
• Self-disclosure of information of a personal nature to a patient;
• Inappropriate physical contact, flirtation, and/or discussion of sexual attraction;
• Feelings of personal responsibility for patient progress;
• Patient demonstrates obvious preference for a particular nurse.
When nurses recognize any of these warning signs in their own behavior, they need to reflect and review motivations and should adjust practice accordingly.
Questions to consider include:
• Whose needs are being met by this behavior and/or interaction, mine or the patients?
• Does this serve the best interest of the patient and promote the patient's needs?
• How would this be viewed by the patient, their family or my colleagues?
• Would I be comfortable documenting this behavior or decision in the patient's progress record or care plan?
• Does my behavior with this patient differ from my usual professional behavior?
• Does this contradict the guidelines set forth in the Scope and Standards of Nursing Practice and the Code of Ethics for Nurses?
It is the nurse's responsibility to abstain from inappropriate behaviors and/or interaction with patients and enforce appropriate boundaries within the nurse-patient relationship. Safety, trust and ethical behavior underpin the professional relationship in the primary interests of patients' ultimate health.
The crossing of professional boundaries has multiple dimensions that include sexual misconduct, inappropriate acceptance of gifts and inappropriate self-disclosure. The nurse must maintain an awareness of the varying vulnerability aspects of patients and the imbalance of power in the professional relationship. The nurse has more power due to patient's divulgence of information of a personal and private nature.
Any exploitation of the relationship between the patient and the nurse for the gratification of the nurse is an abuse of power. It is important that nurses maintain a professional support structure to provide feedback and advice on the management of professional boundary issues as it impacts on their practice. These supportive mechanisms will assist the nurse in identifying the risks of breaching professional or personal boundaries and adversely impacting a patient's well-being.
Felts, J. (2000). Ethical concepts related to professional nursing. Ethical Concepts Module. Retrieved Jan. 20, 2004, from the World Wide Web: http://www.via-christi.org/VCWichita.nsf/875f388dabf60ae386256b7b0055e80c/aa45df54158596d486256bd500675f71/$FILE/ethical_module.pdf
Goin, M. (1998). Borderline personality disorder: Splitting countertransference. Psychiatric Times, 15(11), Retrieved Feb. 21, 2004, from the World Wide Web: http://www.psychiatrictimes.com/p981153.html
Nurses Registration Board. (1999). A project report to the nurses registration board of New South Wales on the development of guidelines for registered and enrolled nurses regarding boundaries of professional practice. Retrieved April 2, 2002, from the World Wide Web: http://www.nursesreg.nsw.gov.au/bounds/guidelin.htm
Jacobson, G. A. (2002). Maintaining professional boundaries: Preparing nursing students for the challenge. Journal of Nursing Education, 41(6), 279-281.
Medical Council of New Zealand. (2004). Draft: Boundaries for the doctor-patient relationship. Retrieved Feb. 20, 2004, from the World Wide Web: http://www.mcnz.org.nz/about/forms/boundariesforDocPatient.PDF
Australian Nursing Council. (2003). Code of professional conduct. Retrieved Feb. 20, 2004, from the World Wide Web: http://www.anc.org.au/02standards/codes.php
Ronayne, S. (2001). Editorial: Nurse patient partnerships in hospital care. Journal of Clinical Nursing, 10, 591-592. Retrieved Feb. 21, 2004, from the World Wide Web: www.blackwellpublishing.com/specialarticles/jcn5.pdf
ANA. (2001, March).1.2 Relationships with patients. Code of ethics for nurses. Retrieved Feb. 21. 2004, from the World Wide Web: http://www.nursingworld.org/ethics/chcode10.htm#1_2
Peternelj-Taylor, C. (2002). Professional boundaries. A matter of therapeutic integrity. Journal of Psychosocial Nursing Mental Health Services, 40(4), 22-29.
Flaherty, M. (1998). Crossing the line: Pushing the limits of professional boundaries. Retrieved Jan. 20, 2004, from the World Wide Web: http://www.nurseweek.com/features/98-10/involve.html
Roberts, J.C. (2002). Keeping your ethics professional: A resource for mental health clinicians: Boundaries in clinical practice. Retrieved Feb. 27, 2004, from the World Wide Web: http://www.judyroberts.net/boundaries_in_clinical_practice.htm
Willson, B. & Winslow, W. (2002, October). Client relationships: Establishing professional relationships and maintaining appropriate boundaries. Nurse to Nurse. Retrieved Jan. 20, 2004, from the World Wide Web: http://www.rnabc.bc.ca/pdf/profboundaries.pdf
Roberta Waite is an assistant professor at Drexel University College of Nursing and Health Professions, Philadelphia, PA.