Within Boundaries

Occupational Hazard
In the therapeutic relationships nurses and other healthcare professionals form with patients, interactions of personal boundaries occur. Several factors of this relationship are unique to caregivers and may predispose them to boundary crossings. These include the intimacy of relationships formed between nurses and patients/families; the reality of long-term relationships, often in the patient's home or other informal settings, often without supervision; and simply the compassion and caring that define nursing/practice. These can result in indiscretions that violate the tenets of therapeutic nurse-patient relationships.

Some experts who study professional boundary issues believe the nature of relationships between caregivers and patients often is an occupational hazard.1

The ANA code statement related to professional boundaries can be widely interpreted. This ambiguity does little more than remind nurses there is a standard to be upheld. In 1996, the National Council of State Boards of Nursing (NCSBN) agreed upon the definitions of professional boundaries, boundary crossings and boundary violations (see Fig. 1). However, this information was published more than 10 years ago, and there is a scarcity of current literature and research studies addressing the gray areas of this thorny issue.

Few Nurses Disciplined
Of 24 state nurse practice acts reviewed in a 2007 study, 22 address boundary violations, specifically dual relationships (role of a nurse versus role of a relative or neighbor) and sexual violations.1 Yet the study showed a low number of nurses are disciplined for misconduct by state nursing boards. Between 2000 and 2006, only 141 RNs were reported to the Healthcare Integrity and Protection Data Bank under the categories of misconduct and sexual misconduct.1

Most experts believe boundary violations are underreported and do not result in the practitioners being disciplined. In the Virginia Board of Nursing's spring 2001 newsletter, Board President Janet B. Younger, PhD, RN, addressed the issue of professional boundaries. She wrote that, in her 5 years on the board, she frequently observed allegations in disciplinary matters concerned "failure of enactment of the professional role."

Abuses Cited
Younger noted some of the allegations included such behaviors as taking loans, property or valuable gifts from a patient; taking children or other relatives to work and allowing them to be in contact with the patient or the patient's property; burdening the patient with the nurse's own personal problems; too much self-disclosure; or significant personal or sexual involvement with the patient.2

"Some nurses seem simply not to know how to behave as professionals," Younger writes. "For others, the pressures of personal problems cause them to act on their own needs rather than those of the patient. Professions have a duty to protect the public, patients and their practitioners from the abuses that can occur in the enactment of the professional role and take action to educate, identify problems, rehabilitate and discipline practitioners."

Continuum of Professional Behavior
To provide nurses with a point of reference against which to evaluate themselves and their colleagues, NCSBN developed the continuum of professional behavior in 1996. This simple indicator helps nurses determine if their relationships with patients are therapeutic or non-therapeutic. (See Fig. 1 below.)

Are your interventions with patients within the zone of helpfulness? Or would you rate your interventions as nontherapeutic? On the left side of the continuum, a nurse's relationships are described as being distant and underinvolved. While it may seem there is no breach of professional boundaries here, patient neglect can result from this noninvolvement. To the right of the zone of helpfulness on the body boundary continuum is any behavior that results in overinvolvement with patients. The most common of these, such as nontherapeutic relations with patients, accepting gifts, dual relationships and self-disclosure, will be discussed later.

Therapeutic Relationships
Nurses enter therapeutic relationships with patients to provide safe and competent physical, psychosocial, spiritual and ethical care. According to the NCSBN definition of professional boundaries, there always is a power differential between nurses and patients. The power of nurses comes from their professional position and access to knowledge about patients as well as the patients' vulnerability due to their illness and need for care.

It is the responsibility of nurses to maintain professional boundaries and ultimately set limits on this power differential. However, as discussed previously, more state boards of nursing are now enacting regulations related to professional boundaries that protect patients and nurses.

To help nurses differentiate a therapeutic relationship from one that is nontherapeutic, NCSBN has identified five guiding principles:

  • have respect for human dignity;

  • avoid personal gratification at the client's expense;

  • do not interfere in a client's personal relationship;

  • promote client autonomy and self-determination; and

  • promote a fiduciary relationship (one that is based on trust).

    Breaching Boundaries
    Nurses get into trouble and breach professional boundaries when they fail to follow the principles of a therapeutic relationship. Often, boundary crossings that lead to boundary violations are not deliberate. Many begin inadvertently, such as nurses showing favoritism for certain patients, giving out their telephone numbers, thinking only they can provide the care a patient needs, exhibiting co-dependent behaviors, and socializing with patients off duty and after patients are discharged.

    If nurses have doubts about their professional behavior with patients, it's their responsibility to discuss the situation with a colleague, a manager or state board of nursing consultant. For example, a nurse employed on a surgical unit of a hospital cared for a young man who was discharged. Two months later at a social function, the two met again. The former patient asked the nurse to dinner. Before she accepted the invitation, she discussed the situation with her manager. Because enough time had lapsed since the young man had been discharged, and the nurse's behavior was professional when she cared for him, the manager told her accepting the invitation was appropriate.

    Accepting Gifts
    Accepting inexpensive gifts from patients for care given when it is presented as token of gratitude may be acceptable. For example, in many cultures, simple gift-giving to caregivers, like a special food, is common and the nurse refusing the gift would harm the therapeutic relationship.

    When choosing to accept a gift from a patient, the nurse needs to consider the context of the situation in which the gift is offered, if the patient expects a difference in the level of care or feels obligated to provide gifts to caregivers, the employer's policy on gift-giving by patients and the value of the gift in economic terms. If a patient wishes to reward a nurse for the care provided with money, some facilities do allow a contribution to be made to a charitable organization in honor of the nurse.

    Dual Relationships
    Nurses are likely to encounter the issue of dual relationships at some time in their career. It's important they know how to deal with this complex situation.

    Dual relationships arise as a result of a previous relationship a nurse has with a patient. Usually this association is that of a family member, friend, neighbor or professional colleague. This relationship already is established through personal, social or financial connections. If this situation occurs in a hospital setting, nurses must inform their supervisor and ensure minimal contact with the patient to preserve the professional relationship.

    In small communities, particularly in rural areas, dual relationships are almost unavoidable. However, nurses must still maintain therapeutic nurse-patient relationships to prevent boundary crossings.

    Information Disclosure
    Access and disclosure of information to and about patients can be a slippery slope for nurses attempting to maintain professional boundaries. Nurses may use self-disclosure or the sharing of personal information with the goal of establishing a therapeutic relationship.

    In the case described previously in this article, Paula shared information about her previous miscarriages with her patient Mary. In this case, as most times when nurses self-disclose, the emphasis may quickly shift to meeting the caregiver's needs rather than the patient's. If nurses doubt they can set limits on self-disclosure, it is better to err on the side of caution.

    Model Education Program
    Nurses bear the responsibility for maintaining professional boundaries, but they need help from colleagues, supervisors, educators and boards of nursing. As discussed in this article, resources available to nurses regarding how they can ensure the care they provide is within the zone of helpfulness are not always clear.

    Nursing students, new graduates and veteran nurses encounter situations that may threaten professional boundaries. All nurses need to regularly review information to ensure their interventions do not result in boundary crossings or violations, according to Gloria Jacobsen, PhD, RN, associate professor at the Loyola University School of Nursing in Chicago. In the June 2002 Journal of Nursing Education, she discusses the importance of preparing students how to identify and intervene before boundary crossings occur.3

    Jacobsen developed a three-step program to help nursing students identify how to maintain professional boundaries and avoid boundary violations. After classroom instruction, students had clinical assignments to observe professional boundary violations and then to identify suggestions about how professional boundaries could be maintained in the situations they observed.

    What resulted from Jacobsen's inclusion of this content in the curriculum, as described by her, was "compelling evidence this issue merited serious attention in a systematic manner." The educator noted this learning activity was simple to implement, required minimal time, yielded markedly different responses from students and could easily be adapted for nursing service.

    Warning Signs
    Finally, to help nurses avoid boundary issues that may result in violations and disciplinary actions, a preventive measure is to frequently refer to a list of the warning signs and questions that may indicate when they or their colleagues are approaching a slippery slope. (See Fig. 2 below.) Maintaining professional boundaries is every nurse's responsibility.

    References

    1. Holder, K., & Schenthal, S. (2007). Watch your step: Nursing and professional boundaries. Nursing Management, 38(2), 24-29.

    2. Younger, J. (2001). Professional boundaries. Retrieved May 1, 2007 from the World Wide Web: http://www.dhp.virginia.gov/nursing/newsletters/NursingNotesSpring2001.doc

    3. Jacobsen, G. (2002). Maintaining professional boundaries: Preparing nursing students for the challenge. Journal of Nursing Education, 41(6), 279-281.

    Resources

    Bensing, K. (2003). Understanding the mystery of body image. Advance for Nurses, 5(7), 17-21.

    National Council of State Boards of Nursing. (1996). Professional boundaries: A nurse's guide to the importance of appropriate professional boundaries. Retrieved April 20, 2007 from the World Wide Web: https://www.ncsbn.org/ProfessionalBoundariesbrochure.pdf

    Waite, R. (2004). Maintaining boundaries. ADVANCE for Nurses, 6(12), 41-44.

    Kay Bensing is senior nurse consultant at ADVANCE and a former psychiatric nurse.

    Fig. 1: Boundary Crossings & Violations

  • Professional boundaries are the spaces between the nurse's power and the client's vulnerability. The power of the nurse comes from the professional position and the access to private knowledge about the client. Establishing boundaries allows the nurse to control this power differential and allows a safe connection to meet the client's needs.

  • Boundary crossings are brief excursions across boundaries that may be inadvertent, thoughtless or even purposeful if done to meet a special therapeutic need. Boundary crossings result in a return to established boundaries but should be evaluated by the nurse for potential client consequences and implications. Repeated boundary crossings should be avoided.

  • Boundary violations can result when there is confusion between the needs of the nurse and those of the client. Such violations are characterized by excessive personal disclosure by the nurse, secrecy or even a reversal of roles. Boundary violations can cause delayed distress for the client, which may not be recognized or felt by the client until harmful consequences occur. Professional sexual misconduct is an extreme form of boundary violation and includes any behavior that is seductive, sexually demeaning, harassing or reasonably interpreted as sexual by the client. Professional sexual misconduct is an extremely serious violation of the nurse's professional responsibility to the client. It is a breach of trust.

    Source: National Council of State Boards of Nursing (1996)

    Fig. 2: Warning Signs of Boundary Crossings

  • Frequent thinking of the patient while away from work

  • Socializing with 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

    >>When nurses recognize any of these warning signs in their behavior or that of their colleagues, they need to reflect on the behavior and adjust practice accordingly. This requires nurses to approach colleagues directly and nonjudgmentally if they observe inappropriate behaviors with patients.

    Consider these questions when assessing professional behavior:

  • Whose needs are being met by this behavior and/or interaction-mine or the patient's?

  • Does this serve the best interest of the patient and promote the patient's needs? <% footer %>

  • Within Boundaries

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