Caution! Don't Cross that Line - Maintaining Professional Boundaries

tnbutterfly - Mary, BSN

Unlike personal boundaries which you set for yourself, many professional boundaries are already established and are less flexible.The American Nurses Association's (ANA) Code of Ethics for Nurses and the National Council of State Boards of Nursing set out clear expectations for therapeutic and professional nurse-client relationships. Laws create some boundaries; other limits are set by the NCSBA as a licensing body and others by practice setting policy. Still other expectations of conduct are established by the individual professional. These expectations influence how we behave with people as clients. Your challenge as a nurse is to maintain these boundaries while providing safe, competent, ethical nursing care.

Professional boundaries in nursing are alluded to in the Nightingale Pledge used, first by new graduating nurses in 1853, and, in many pinning ceremonies since.

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....I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and family affairs coming to my knowledge in the practice of my calling....
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According to the National Council of State Boards of Nursing...

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"as a health care professional, a nurse strives to inspire the confidence of clients, treat all clients and other health care providers professionally, and promote the clients' independence. Clients can expect a nurse to act in their best interests and to respect their dignity. This means that a nurse abstains from obtaining personal gain at the client's expense and refrains from inappropriate involvement in the client's personal relationships."

The American Nurses Association's code of ethics also addresses professional boundaries.

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"When acting within one's role as a professional , the nurse recognizes and maintains boundaries that establish appropriate limits to relationships. While the nature of nursing work has an inherently personal component, nurse-patient relationships and nurse-colleague relationships have, as their foundation, the purpose of preventing illness, alleviating suffering, and protecting, promoting and restoring the health of patients."

Every U.S. state has a nursing regulatory agency, which is most often a board of nursing. These agencies are given the responsibility of protecting the public which they do via the Nurse Practice Act in each state which is made up of statutes, rules, and regulations.

The Nurse Practice Act is the foremost legal document regulating nursing. It's credited with protecting the public, defining nursing practice, describing practice boundaries, establishing standards for nurses, and protecting the domain of nursing. Used by courts and boards in disciplinary endeavors, the Act is the basis in determining the appropriateness of nurses' actions

It is obvious that the nurse-patient relationship differs greatly from a personal relationship. It is crucial for all health-care professionals to recognize the differences between the therapeutic relationship and other types of non-professional relationships. Patients are very vulnerable as nurses interact with them, sometimes in a very intimate way, in times of stress and health challenges. Because of this, as well as the fact that nurses and other health care professionals have access to private knowledge about the patient, a nurse has power over the patient. Establishing and maintaining boundaries allows the nurse to meet the needs of the patient without abusing the professional power and taking advantage of the patient's vulnerability.

The nurse's professional behavior can be viewed as a continuum, with the desired level of helpfulness in the center. This is where most of the nurse-patient interactions should occur. On one side of the continuum is over-involvement with a client. This could include doing too much for the patient, sharing too much personal information, sexual misconduct. On the opposite end is under-involvement, including distancing, disinterest, neglect. There is a gradual transitioning from one end to the other. Healthy professional boundaries are flexible within the limits of applicable laws and reasonable professional judgement. The nurse or patient may intentionally cross a professional boundary for a period of time to establish or maintain a therapeutic relationship. The key is to recognize what is helpful crossing and what is not. Sometimes, it will be necessary and even therapeutic to briefly go toward either end. For example, if a patient seems too clingy or attached, it may be wise to distance yourself from that patient, not to the extent of neglect, but enough so that the patient realizes that others, including him or herself, can meet the needs. In this instance, the boundary crossing is for the patient's best interest.

Confusion between the needs of the nurse and the needs of the client can result in boundary violations, leading to distress for the patient. This can occur as a result of excessive personal disclosure by the nurse or even a reversal of roles where the patient feels the need to meet the nurse's needs.

The following is a partial list of boundary violations:

Picking up groceries for a homebound patient
Giving/receiving a gift to/from patient
Social contacts with former patients or their relatives including sexual relationships
Speaking ill of a co-worker or employer
Making rude or inappropriate comments about a patient
Sharing personal problems or aspects of your intimate life with a patient
Giving certain patients unnecessary extra time or attention
Talking to patients/families about things that are out of your scope of practice
Sharing personal health information with others not directly connected with the care of a patient
Neglecting to protect the dignity of the patient as much as possible
Flirting with a patient

Professional boundaries set limits to the nurse-client relationship, which establishes a safe, therapeutic connection between the professional and the person who seeks care. Health professionals should never forget that clients frequently let us into their homes and their hearts. We should do everything to protect the trust of our clients and their families by our careful attention to the professional boundaries of our relationships with them. Have you ever crossed the line?

For other articles by this author, go to Body, Mind, and Soul

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Caution! Don't Cross that Line - Maintaining Professional Boundaries

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