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

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by tnbutterfly - Mary tnbutterfly - Mary, BSN, RN (Admin)

Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

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?

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

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.

Quote
....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....
1

According to the National Council of State Boards of Nursing...

Quote
"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.

Quote
"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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tnbutterfly (AKA Mary) is the allnurses Content and Community Director. Let her know if you have questions, comments, or need assistance.

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12 Comment(s)

VICEDRN, BSN, RN

Specializes in ER. Has 5 years experience. 1,078 Posts

Hee hee...

Some of these made me laugh...

What is "personal problems of aspects of my intimate life"? Anybody with guesses, enter them for me please!

Know I already screwed up...gave some patients more attention than others...what can I say they were crimping and the others? Not so much!

mrshan64

mrshan64

3 Posts

I have always and will continue to maintain strict professionalism. This post is an excellent "reminder" of our nursing role. We have to exercise common sense at all times when in the nursing capacity. Sharing your personal problems with any patient or family is not an option. This is a very serious matter. It is included in the Nurse Practice Act and if you look in your policy and procedure manual at your place of employment you will find it there also. Please take this very seriously because while you may not have incurred negative consequences on each of the other times boundaries were crossed with the patient you, no doubt, are not exempted from repercussions down the line with repeated and/or chronic violations. I employ you to consider taking the policies, statutes, guidelines, and codes that govern our practice very seriously for the sake of added value given healthcare. Thank you for your time and attention to this important part of our profession and thank you tnbutterfly for your review and question toward this topic.

elprup, BSN, RN

Has 2 years experience. 1,005 Posts

Just another reason why non nurses, who call themselves nurses, are not nurses. I should not generalize like this and i apologize for offending all the non nurses who provide excellent professional care. I wish you worked at my clinic because our MA's are sorely lacking it.

dudette10

dudette10, MSN, RN

Specializes in Med/Surg, Academics. Has 11 years experience. 1 Article; 3,530 Posts

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?

No, I have never crossed the line, but one particular patient I had recently made me think long and hard about how easy it would be to cross it. I liked her a lot, she had a heart-breaking diagnosis, her attitude was inspiring...in short, she could have been my best friend. I became more aware of my personal feelings toward her, and I was cognizant and careful of the nature of my interactions with her.

She got to me. I cried about her when I got home. I'm glad I've had this lesson so early in my career.

dudette10

dudette10, MSN, RN

Specializes in Med/Surg, Academics. Has 11 years experience. 1 Article; 3,530 Posts

Hee hee...

Some of these made me laugh...

What is "personal problems of aspects of my intimate life"? Anybody with guesses, enter them for me please!

Know I already screwed up...gave some patients more attention than others...what can I say they were crimping and the others? Not so much!

I can give a go at it. When you have a patient who is close to your own age, same stage of life, and who wants to talk to you about personal things in her own life that become a problem d/t her own diagnosis. You cannot reply to her in a way that sounds like you are having a phone conversation with your BFF, where you share your own similar struggles or provide inappropriate advice. :)

goltzilocks

goltzilocks

11 Posts

This was a very thought provoking post tnbutterfly. For me personally, I really try to treat my patients as if they were my own family member because that is how I would want myself or my own family treated. I feel sometimes it is necessary to "humanize" ourselves with our patients. They need to feel our kindness, compassion, empathy, and understanding for them. For example, I have type II diabetes. I really try to help my patients understand how serious diabetes is and how important it is to get regular check ups, etc. If I have a patient who is struggling, sometimes (not all the time), I do share with my patient that I am diabetic and may share something that has personally helped me. Is this crossing the boundary, I don't know, I hope nobody blasts/flames me for this post. I really love people and I try to help my patients and my co-workers in every way I can. There is much suffering in the human race and we all need each other. Just knowing someone else understands your illness can really help a patient. Also, as nurses, dealing with patients troubles and illnessess can weigh us down. How many of us have cried on the way home a time or two? We need to support each other as much as we support our patients.

nerdtonurse?

nerdtonurse?, BSN, RN

Specializes in ICU, Telemetry. 3 Articles; 2,043 Posts

I love the "flirting" one....the average age of my patients is 32 years older than I am, according to last month's stats...so, not so much flirting.

msn10

msn10

Specializes in cardiac, ICU, education. Has 18 years experience. 560 Posts

I am teaching a rural nurse residency program right now and it is virtually impossible to take care of someone that you don't know when you work at a hospital with 25 beds. One of our modules is "Visibility in the Community - Always a Nurse"

Thanks for the quotes from the professional orgs. I will use them in my next presentation.

Nurse SMS, MSN, RN

Specializes in Critical Care; Cardiac; Professional Development. Has 11 years experience. 2 Articles; 6,837 Posts

This was a good read for me, a new grad just getting started. I had a patient last week that I bonded with and who I cried about on the way home a little bit and who has been in my thoughts somewhat on the days off I have had since. It got me to thinking about professional boundaries, not because I crossed any or was tempted to, but simply because I think when you get emotionally involved crossing those lines would be easier to do. A conscious review of them, I guess you could say. I admit though, it is really hard to imagine telling a patient my personal problems or to imagine having sexual feelings toward one of them. :uhoh21:

bxpansive

bxpansive

9 Posts

There are some excellent, short books on professional boundaries for caregivers and healthcare workers. They read easily and offer examples and solutions. The chapters flesh out the subject in a human and applicable way; not just through do's and don't rules. They may not be directly addressing nursing, but they are for healthcare providers of one discipline or another.

tnbutterfly - Mary, BSN, RN

Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg. 154 Articles; 5,900 Posts

Yes, there are several books. Please feel free to share any books on the subject that you find particularly helpful.