Professional Boundaries in Nursing- Full Version

Professional Boundaries in Nursing- Full Version

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– 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.

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