- Mary, a home health nurse has been providing care to Dorothy for more than
six months. The two of them have enjoyed pleasant conversations and discovered
several mutual interests. Dorothy genuinely likes Mary and is grateful for
the excellent care she's provided. Their friendly relationship has always remained
on a professional level until today when Dorothy overhears Mary telling a friend
about her financial problems. When Mary ends her phone call Dorothy offers to lend
her money. Hesitant at first, Mary eventually accepts a loan and in doing so
commits a serious violation of professional boundaries.
Nurses inspire confidence in their patients by treating
them professionally, objectively, and ethically. Patients and their
families expect nurses to always act in their best
interests and to adhere to the standards of professional conduct while maintaining
a respectful and professional relationship, but nurses have a type of
authority and influence that comes from their professional position. Their
specialized knowledge and skills as well as access to private information make the
patient vulnerable. The inherent difference in this relationship requires
boundaries to help nurses establish and maintain limits in their professional
interactions with patients. By using professional judgment to determine and
stay within appropriate boundaries, nurses can meet their patients needs. On the
other hand, nurses who put their personal needs ahead of their patients needs will
cross over these professional boundaries. These types of behaviors violate laws and
regulations that are designed to protect the public, as well as meet the standards
of professional conduct.
Every nurse/patient relationship can be depicted on a continuum of professional
behavior. At the center of the continuum is what is commonly referred to as the
therapeutic nurse/patient relationship. This relationship protects the patient's
dignity, autonomy, and privacy. Under- involvement by the nurse is characterized
by distancing, disinterest, and neglect. These types of behavior create an
imbalance in the nurse/patient relationship. At the other end of the
continuum is over-involvement. Almost all professional boundary crossings and
violations occur at this end of the continuum. The continuum serves as a frame
of reference for helping nurses evaluate their own and their colleagues
interactions with patients. Unfortunately, while some boundaries are clear-cut,
others may not be quite so easy to recognize at first.
Let's take a look at the different types of over-involvement.
We'll use a few examples to help us illustrate these behaviors.
Boundary crossings, which are sometimes called
boundary drifts are brief excursions across professional lines of behavior. The
behavior is often inadvertent but sometimes the behavior can be purposeful
and is used to meet a perceived therapeutic need. For example, Jack is
concerned that his patient Lucy is becoming discouraged with her progress in
physical therapy. Jack knows that Lucy is a fan of his alma mater's basketball team,
so he gives Lucy a sweatshirt to wear during therapy. This is an example of an
intentional boundary crossing with a specific therapeutic purpose in mind.
Boundary crossings can sometimes occur in a therapeutic nurse/patient relationship
but these incidents should be evaluated by the nurse for potential consequences and
implications to a patient because boundary crossings can sometimes lead to a boundary
violation. Boundary violations result when there is confusion between the needs of
the nurse and those of the patient. These violations are characterized by excessive
personal disclosure by the nurse, secrecy, or even a reversal of roles. Let's say
that Jack secretively gives Lucy a sweatshirt and tells her they should go to
a game together wearing their matching sweatshirts. In this case, Jack is putting
his own needs and desires before the patient's. The difference is context. In
the second case, the act of presenting the exact same gift becomes a boundary
violation. Mary's acceptance of a loan from Dorothy is another example of a
boundary violation. By allowing Dorothy to learn of her financial issues, Mary
disclosed too much information about her personal life. When she accepted a loan
from her patient, Mary placed her personal gain ahead of her patient's best
interests. Professional sexual misconduct is an extreme form of boundary violation.
It includes any behavior that is seductive, sexually demeaning, harassing,
or reasonably interpreted as sexual by a patient. Professional sexual misconduct
creates a breach of trust and this is an extremely serious violation of the nurses'
professional responsibility to a patient. Violations of the Nurse Practice Act are
addressed by Boards of Nursing depending on the laws and regulations of the
jurisdiction as well as the severity and context of the boundary crossing or
violation. Consequences may range from verbal warnings to license
suspension or revocation.
So, how can we identify potential boundary crossings and violations before
they happen? Nurses who display one or more of the following behaviors should
examine their patient relationships for possible boundary crossings or violations:
excessive self-disclosure, secretive behavior, special treatment, flirtation,
or overprotective behavior. Any of these behaviors may indicate a shift from the
therapeutic nurse/patient relationship to over-involvement with the patient. Once a
nurse becomes over-involved in the patient's world, the professional
relationship is betrayed.
Many of these behaviors may have a reasonable
explanation, however, if a pattern emerges, it's time to stop and evaluate
the behavior and possibly talk with a colleague or mentor. The earlier a nurse
evaluates behaviors and seeks help, the greater the chances of returning to the
therapeutic nurse/patient relationship. Take the case of Katy, a nurse caring for
a late stage cancer patient, Cindy. Cindy's husband Joe is having trouble
coping with his wife's illness. Wanting to comfort Joe, Katy has drifted from
conversations with him outside his wife's room to having coffee with him in the
hospital's cafeteria. Now, Joe is calling Katy at home and posting comments on
social media, saying she's the only person who really understands what he's going
through. Uncertain what to make of the situation, Katy talks to her nurse manager
who helps Katy understand that, while her intentions are good, her actions
constitute inappropriate over-involvement with a patient's family.
Because she is open to assessing her professional relationships and sharing her
concerns with her manager, Katy is able to return to patient-centered care before a
boundary violation occurs. If Katy hadn't recognized the warning signs and talked to
her manager, the crossing could have escalated to a boundary violation.
Boundary crossings can happen to any nurse. The key to avoiding them is
continual alertness, self evaluation and emphasis on the patient's best interests.
In respecting professional boundaries, nurses protect their patients, themselves
and the profession.