Professional Boundaries in Nursing

By Kim Holland on Tue, Jul 02, 2013

boundaries in professioanl nursingThe violations of professional nursing boundaries are almost always to make ourselves come across to the patient as the victim. It does not matter whether you are whining to a patient about your personal life or accepting a gift, you have altered the role of caregiver to the person in need of care.

"Boundaries are mutually understood, unspoken physical and emotional limits of the relationship between the patient and the nurse." (Farber, 1997)

 

When these limits are altered, what is allowed in the relationship becomes ambiguous and possibly unethical. The health and well being of patients depends upon a collaborative effort between the nurse and the patient. Patients are extremely vulnerable to boundary violations because they trust us as their health care providers. They come to us in a time of need, presenting with physical, and often emotional, distress. Some patients demand continuous attention but are unaware of their insatiable neediness. (Muskin and Epstein, 2009)

 

When you speak ill of coworkers or the hospital, you are looking for sympathy from the patient to feel sorry for your situation, whatever that may be. If you speak to a patient about the poor staffing or your inability to perform a task, you instill fear in the patient in order to achieve power. You are using their situation and nurse-patient relationship  for personal gain.

 

Warning signs of unhealthy boundaries could be:
 

  1. You share personal problems or aspects of your intimate life with patients.
     
  2. You keep secrets with patients.
     
  3. You become defensive when someone questions your interaction with.
     
  4. You have received gifts from a patient.
     
  5. You speak to the patient about your own professional needs or inability.
     
  6. You speak poorly of co-workers or the hospital to patients.
     
  7. You talk to patients/families about things that are out of your scope of practice.
     
  8. You give certain patients extra time or attention.
     
  9. You give patients personal contact information or money.
     
  10. You fail to set limits with a patient.
     
  11. You spend duty time with patients.
     
  12. You feel that you understand the patient’s problems better than other members of the healthcare team.

Communication in nursing is vulnerable to boundary problems. Nurses who have patients with extended length of stay or treatment are especially vulnerable. 

 

To be more aware of boundary issues you may be unaware of, begin to listen to what you say to patients. Is your tone, approach and conversation professional? Is there a clear distinction that this is your patient and you are the professional nurse? Are you telling the patient or family specific information for personal gain? 

 

If you see other nurses violating professional boundaries, you do not help the patient or the nurse by not bringing the issue of proper patient care to someone's attention. Take the time to mentor less experienced nurses with what they could have said, or other choices. If the violation is repeated, you need to inform the nurse’s supervisor. 

 

Boundary violations occur one small step at a time and almost always without warning, yet if we are aware, the warning signs are there. What appears to be innocent may end up being a commitment to an unprofessional relationship with a patient. 

 

In dealing in boundary violation in professional nursing, the best thing you can do is to remain mentally healthy. Take time to take care of yourself and your family. If you are feeling vulnerable with a specific situation or patient, do not be afraid to ask a peer to help you by taking that patient assignment. 

 

References:

Farber, N, Novak, D, O’Brien, M. Love, Boundaries, and the Physician-Patient Relationship Arch Int Med 1997;157: 2291-2294.

 

Muskin, P,Epstein, L. Clinical guide to Countertransference. Current Psychiatry 2009; 8:25-32



22 COMMENTS

Anonymous 2 weeks ago
Thanks for writing such a great post. I really enjoy reading that content. Please keep up the good work. Coursework Mark

Anonymous 7 months ago
This doesn't make any sense. How can you be married and the marry again soon? The rest of this article is junk. Try writing it again to make more sense.

Anonymous 2 years ago
I like this article. I don't think the author is saying don't interact as a human being with your patients. I think boundaries are often flexible, but necessary. Patients don't need to know our entire life story. They are sick or injured and should focus on getting better. Telling them you are married with three children should be o.k., but discussing your third child's ADHD issues and your husband's recent layoff are over the line. Taking presents or money are definitely not professional and in most hospitals not permitted. If they insist, suggest a donation to the hospital. If we become too involved with personal issues we can lose sight of patient's issues for being there and in some cases miss something importance (this happened in a child abuse case that I observed once. The nurses, over involved with the mother of a child, could not believe she would harm her own child. Eventually this was proved, but could it have happened earlier with less trauma to the child? I think so.)

Anonymous 3 years ago
Very well written article. I definitely believe in having boundaries with everyone, pt and coworkers alike. I do feel totally comfortable sharing a certain amount of personal info, if the patient is interested. I think that helps to form a healthy relationship with patients, but whining about your problems in life and at work is definitely a no-no.

Anonymous 3 years ago
I'm all for healthy professional boundaries, but: "You instill fear in the patient in order to achieve power."?? Yikes! A little harsh, don't you think?

Anonymous 3 years ago
We must always be professional in our approach to a pt, however they are not just objects we treat and street. I believe that we also go through trials and tribulations just as our pt's do. This is a learnig process. I feel quite comfortable sharing hope and encouragement and most of all compassion. In the past 30 years, copassion has flown out the window. This is now a money making business. The object is to treat and street as soon as possible. There is no time to be compassionate because it just might take too long.
I had breast cancer. I had a mestectomy with reconstruction, the graft site died and became grossly infected. That nearly killed me. When I beceame well after 3 months of hospitalization, I underwent chemo and indured all of the great side effects it has to offer. I, by the grace of the Lord after 10 years is still here. I do share with breast ca pt that I too had breast ca and offer encouragement. I do not share all the details. The expression on a pt's face I have witnessed is priceless. I can say with all authority to the pt; I know how you feel and this is just a bend in the road. They tell me that telling them this made them feel comfortable knowing that " your not blowing smoke. You really do know how I feel". We as care givers are not above the pt's. Some day you will be on the other side of the bed looking up at your care giver.

Anonymous 3 years ago
I do not think answering those personal questions are wrong, because, sometimes patients need such bits of information to make up their minds in trusting your care. After answering such questions, you should steer the conversation around and make it patient-centered, and use it in your ongoing assessment of response to care.

Anonymous 3 years ago
After 17 years in nursing, I agree with the article regarding personal conversation, and understand Mario's point. If you look at Kim's article she is describing "intimate" details, which I don't feel includes causal conversation. I believe our job as Nurses is much more about listening than talking about ourselves. This seems to be the one issue we are debating, I don't think anyone of us should disagree with any of the other points

Anonymous 3 years ago
I feel like uncomfortable when a patient ask how long are you married or do you have kids. I usually answer then quickly change the subject. Thanks for the point, because i didnt think of it as crossing boundaries. So whats the best way to avoid answering personal questions without being rude.

Anonymous 3 years ago
I have heard many patients say they appreciated the health provider who acted interested in them personally. While I strongly believe in professional boundaries; when I have been a patient, or on the receiving end, I truly appreciate the caregiver who makes the attempt to connect with me and empathize. "Kind" "Customer service" is just what it is. Lip work. I prefer the caregiver who goes a bit beyond that. I do, but it is only for the clinical setting. I try to see exactly where each client comes from when I assess their needs.

Anonymous 3 years ago
I agree with Mario that as nurses we must be holistic in our approaches to patient care. However the important point of this article is that sometimes nurses go over the line, and can become overly involved with patients in a non-therapeutic way. What we bring to the healing experience is our caring and compassion, our honesty and integrity, our knowledge and experience, our sense of humor, and a strong sense of doing no harm. We are there to provide the highest level of care to every patient. Do we treat different patients differently? Do we give a little extra time to the patients we like, and a little less time to the patients who are hard to get along with? Of course we do. Do we share our stories of hope? Yes, it’s part of the process. What we have to be careful of is maintaining our professionalism, while providing a quality healing experience. Everything we do is in service of the patient, and taking care of their needs. Secondary to that is the fact that the nurse gets to feel good about having done a great job. When it becomes primarily about us, we are on the wrong side of the line. This article gives some good guidelines that we should all be willing to consider to assure that we stay within the boundaries of a healthy nurse-patient relationship.

Anonymous 3 years ago
what about hospitals that encourage this relationship like Studor group hospitals that foster personal care issues between staff and patient that are more personal than professional at times

Anonymous 3 years ago
I agree to all the points made. The presentation could not be more clear. Thanks

Anonymous 3 years ago
I'm known for getting my patients at an "arms distance", and after nearly 20 years of nursing it's left me feeling a bit sad and cold BUT I have never forgotten about the lecture on professional boundries with patients.Maybe patients should be given a list of things not to ask the nurse. Do you have kids? what are theyre names? where are you from? My standard reply to all these personal questions are a pleasant smile and let them know that revealing personal information about myself would be crossing over into unprofessional practice...

Anonymous 3 years ago
very very true iam recently a retired nurse due to having major back issues mva and allstate is evil not wanting to pay the claim i was not @ fault its just a $ game and lord knows i paid my dues i just made bad choice in men lol i have been blessed wit 3 sons ! adopted from an addicted mom and dad my first ex and her comments to that kiddo almost warped him and after 3 lost baby angels i knw all girls i have 2 bilogical sons and i TRUST IN THE LORD not mankind although difficult the clinic i worked @ alcohol and drug addiction needed serious hlp its sad tat i worked wit such MOM hating ppl i continue to pray for forgiveness is easy forgetting isnt lol i read bible Pslms 27 alot lol lo im still smiling

Anonymous 3 years ago
thankyou Mario

Anonymous 3 years ago
Mario, i so agree with so much of what you've pointed out to us... Personal, holistic care includes sharing ... in sharing our selves with our patients, in a non-threatening and non-demanding way, we promote their confidence not only in us as caregivers, but in the whole medical industry which, unfortunately, sometimes doesn't deserve that confidence at all. Another subject...

Anonymous 3 years ago
I am a nurse who was recently disabled and sought the assistance of a "Disability Navigator" via the state Dept. of Labor. I still love her to pieces, and remain eternally grateful for all her assistance in the past year,but she abruptly terminated the relationship this spring, and I am still in emotional turmoil over it. There can be trust within professional boundaries, w/o the caregiver's need to completely "connect". The needs of the pt., or customer, are the only needs that s/b under consideration.

Anonymous 3 years ago
I find this article to be interesting because in respects it contradicts everything we do as nurses. I agree taking monetary or physical gifts, cultivating non-working relationships with patients, and violating the trust and privacy of patients is unethical. I do think being able to acknowledge you may one patient may need a considerable amount of attention and care versus another patient based on acuity of their conditions, their inability or poor coping skills with illness, or a need to ensure patient safety.
As health care changes, the concept of patient satisfaction will play an enormous role in health care budget and payment schedules. Patient want to be cared for by patient who connect with them on a level provoking trust, empathy, and healing. Being a nurse who cannot connect with your patients on different levels besides a person one is being paid to provide care to is the epitome of how healthcare has morphed from an occupation of service to an occupation of business.
The ability to provide holistic care to patients and their families is what nurses should strive to achieve. When we forget and intentional suppress our humanity and caring qualities, we forget to relate with patient. We forget to inform them triumphs who have walked in our facilities ill with the same or similar illnesses and have walked out healed or content with the what is soon to come in their futures. We forget to acknowledge that the person in the bed sharing with a smile on his or her face, reminds us of the wit, wisdom, and humility of our mothers, fathers, grandparents, neighbors, and friends who have been there and fought their way back to great health or died fighting.
I have been a nurse for nearly 6 years and one of most memorable experiences as a nurse was changing the opinion on how people viewed me based on the color of my skin. My ability to cultivate a relationship with a patient and her significant other in the rural Midwest by sharing personal stories, providing both nursing and social education, and demonstrating nursing is not a task, it is a way of life for me. Through that, I was able to help them find a way to put trust in healthcare, humanity, and me.

Anonymous 3 years ago
Taking photos (cellphone cameras) of patients is a huge violation of patients' rights and I'm sorry to say that it is done every day.

Anonymous 3 years ago
It is very important that we arrange to meet our needs outside of work to lessen any temptation to look for emotional support from our patients

Anonymous 4 years ago
These are excellent pieces of advice. I worked in a state prison for 18 yrs and those are definately the steps that were observed by the overfamiliar nurses, that got caught up with prisoners.