The Discipline of Nursing Professional Boundaries

As professionals in health care, the nurses’ aim is to have a therapeutic relationship with the patient, where boundaries of the relationship are strictly safe and within the code of ethics. Such boundaries are called professional boundaries that are defined as the ‘spaces between the nurse’s power and the client’s vulnerability’. Establishing these boundaries provide the nurse with authority to allow a confidential and professional therapeutic relationship with the patient (The National Council of State Boards of Nursing 2010, p. 25). To avoid breaches and infringement, these boundaries must be maintained throughout clinical practices and placements.

The Australian Nursing and Midwifery Council, also known as ANMC, (cited in Kralik & van Loon 2008, p. 76) define professional boundaries as ‘the limit of a relationship between a nurse and an individual or between a nurse and any significant other persons, which facilitates safe and therapeutic practice and results in safe and effective care’. In regards to nursing, the ANMC (cited in Levett-Jones & Bourgeois, 2009, p. 103) advocates that professional boundaries are related to the responsibility, performance, morals and actions from the nurse and must be maintained when working with vulnerable individuals.

To ensure a professional environment between the nurse and patient, a code of conduct, as well as a set of policies and ethics, are put in place. Daly, Speedy & Jackson (2006, p. 131) states that nursing ethics can be defined broadly as ‘the examination of all kinds of ethical (and bioethical) issues from the perspective of nursing theory and practice’. The most important organizations in Australia that create policies for nurses and other health care professionals to abide by, are the Australian Nursing and Midwifery Council (ANMC), the National Council of State Boards of Nursing, the Australian Health Practitioner Regulation Agency (AHPRA). The policies, as spoken by the ANMC, is generated and expected for nurses to ‘uphold both within and outside of professional domains in order to ensure the good standing of the nursing profession’ (ANMC 2008, p.1). If the organizations’ code isn’t followed, it will establish a breaching of boundaries and professional misconduct, which is defined as the unethical, immoral and improper actions outside of the nurses’ practice (ANMC 2008, p.2).

The continuum of professional behaviors is an evaluation tool for nurses to assess the interaction between the client and the nurse. Seen in this continuum, the zone in the middle is called the ‘zone of helpfulness’ where it verifies if the behavior towards the patient, demonstrated by the nurse, is safe and professional. Breaching of boundaries can be on either side of the zone of helpfulness where on the left hand side is under-involvement and towards the right hand side is over-involvement. Both ends of the continuum generally involve violating and breaching the borders of a therapeutic relationship and are harmful and damaging to both the nurse and the patient (Oregon Sate Board of Nursing 2010, p.12).

Under-involvement is mostly seen when the patient is feeling neglected and isolated. Predominantly, when the nurse abandons the patient, there is a lack of care, which in turn, may be able to increase health risks for the patient. For example, ignoring the patient during two-hourly bed turns could cause bedsores on the patient’s body or paying no attention to the patient’s strict diet could cause food allergies. Disregarding the patient is detrimental to their health and may also be damaging to the nurse (National Council of State Boards of Nursing 2010 p. 25).

Boundary violations are on the over-involvement side of the continuum and are breaches that, at times, intend to harm the patient and sometimes occur when the nurses’ needs are met instead of the patients. An example of such violations can include the nurse providing personal information or feelings to the patient, accepting a gift from the patient or engaging in a sexual relationship with the patient. As health care providers, patients are more susceptible to boundary violations because of vulnerability, high dependency on the nurse and low stability on their mental and emotional state (Nurse Together 2011).

Vulnerable individuals are most important when working with professional boundaries. In the health care profession, vulnerable individuals are usually those that have an extended length of stay or treatment, but can also be those that are of old age, have a high dependency on the nurse, have past trauma or injuries, a high severity of illness and/or a low stability on their emotional and mental state. (Holden & Schenthal 2007, p. 28)

There are many different strategies for a nurse to utilize during clinical placements. The American Nurses Association (cited in Holden, KV & Schenthal, SJ, 2007 p. 25) says that ‘when acting within one’s role as a professional, the nurse should recognize and maintain boundaries that establish appropriate limits to relationships’. For vulnerable individuals, Nurse Together (2011) advocates that boundaries can be maintained by many tools such as using an approachable and professional tone and by having a clear distinction of the professional relationship and the role of the nurse and as the patient. The tone of the nurse can be interpreted in many different ways, thus has the ability to breach the professional boundary between the nurse and the patient. If the nurse is talking with an interested, over-friendly and flirtatious tone, it can be interpreted it as becoming over-involved with the patient as it is engaging in a sexual relationship with the patient. The nurse should always act in the best interest of the client and be cognizant of their feelings and behavior. Nurses should always be aware of the patient and their culture. For example, a patient with different beliefs may view an action in a different manner, which therefore has the ability to become a potential catalyst to an unprofessional relationship (Oregon State Board of Nursing 200 p.14). Therefore, to maintain professional boundaries with vulnerable individuals, nurses should keep within the zone of helpfulness by having a clear distinction that the relationship with the patient is kept professional and the nurse is the health care worker, not the patient.

As a nurse, there are boundaries that must be conserved to have a professional therapeutic relationship with the vulnerable patient throughout clinical placements and/or clinical practices. Organizations such as ANMC and AHPRA generate policies to enable the nurse to take care of a patient at an optimal level and not be over or under involved. If, however, there is a violation of these boundaries, it is considered as professional misconduct. Maintaining these boundaries is important for risk management, quality assurance, client satisfaction and agency resource utilization (Clark et. al, cited in Kralik & van Loon 2007, p. 76).