WEBVTT

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- Mary, a home health nurse has been
providing care to Dorothy for more than

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six months. The two of them have enjoyed
pleasant conversations and discovered

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several mutual interests. Dorothy
genuinely likes Mary and is grateful for

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the excellent care she's provided. Their
friendly relationship has always remained

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on a professional level until today when
Dorothy overhears Mary telling a friend

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about her financial problems. When Mary
ends her phone call Dorothy offers to lend

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her money. Hesitant at first, Mary
eventually accepts a loan and in doing so

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commits a serious violation of
professional boundaries.

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Nurses inspire confidence in
their patients by treating

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them professionally, objectively, and
ethically. Patients and their

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families expect nurses to
always act in their best

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interests and to adhere to the standards
of professional conduct while maintaining

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a respectful and professional
relationship, but nurses have a type of

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authority and influence that comes from
their professional position. Their

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specialized knowledge and skills as well
as access to private information make the

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patient vulnerable. The inherent
difference in this relationship requires

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boundaries to help nurses establish and
maintain limits in their professional

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interactions with patients. By using
professional judgment to determine and

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stay within appropriate boundaries, nurses
can meet their patients needs. On the

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other hand, nurses who put their personal
needs ahead of their patients needs will

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cross over these professional boundaries.
These types of behaviors violate laws and

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regulations that are designed to protect
the public, as well as meet the standards

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of professional conduct.

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Every nurse/patient relationship can be
depicted on a continuum of professional

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behavior. At the center of the continuum
is what is commonly referred to as the

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therapeutic nurse/patient relationship.
This relationship protects the patient's

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dignity, autonomy, and privacy. Under-
involvement by the nurse is characterized

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by distancing, disinterest, and neglect.
These types of behavior create an

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imbalance in the nurse/patient
relationship. At the other end of the

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continuum is over-involvement. Almost all
professional boundary crossings and

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violations occur at this end of the
continuum. The continuum serves as a frame

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of reference for helping nurses evaluate
their own and their colleagues

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interactions with patients. Unfortunately,
while some boundaries are clear-cut,

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others may not be quite so easy to
recognize at first.

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Let's take a look at the
different types of over-involvement.

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We'll use a few examples to help us
illustrate these behaviors.

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Boundary crossings, which
are sometimes called

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boundary drifts are brief excursions
across professional lines of behavior. The

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behavior is often inadvertent but
sometimes the behavior can be purposeful

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and is used to meet a perceived
therapeutic need. For example, Jack is

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concerned that his patient Lucy is
becoming discouraged with her progress in

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physical therapy. Jack knows that Lucy is
a fan of his alma mater's basketball team,

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so he gives Lucy a sweatshirt to wear
during therapy. This is an example of an

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intentional boundary crossing with a
specific therapeutic purpose in mind.

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Boundary crossings can sometimes occur in
a therapeutic nurse/patient relationship

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but these incidents should be evaluated by
the nurse for potential consequences and

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implications to a patient because boundary
crossings can sometimes lead to a boundary

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violation. Boundary violations result when
there is confusion between the needs of

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the nurse and those of the patient. These
violations are characterized by excessive

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personal disclosure by the nurse, secrecy,
or even a reversal of roles. Let's say

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that Jack secretively gives Lucy a
sweatshirt and tells her they should go to

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a game together wearing their matching
sweatshirts. In this case, Jack is putting

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his own needs and desires before the
patient's. The difference is context. In

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the second case, the act of presenting the
exact same gift becomes a boundary

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violation. Mary's acceptance of a loan
from Dorothy is another example of a

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boundary violation. By allowing Dorothy to
learn of her financial issues, Mary

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disclosed too much information about her
personal life. When she accepted a loan

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from her patient, Mary placed her personal
gain ahead of her patient's best

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interests. Professional sexual misconduct
is an extreme form of boundary violation.

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It includes any behavior that is
seductive, sexually demeaning, harassing,

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or reasonably interpreted as sexual by a
patient. Professional sexual misconduct

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creates a breach of trust and this is an
extremely serious violation of the nurses'

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professional responsibility to a patient.
Violations of the Nurse Practice Act are

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addressed by Boards of Nursing depending
on the laws and regulations of the

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jurisdiction as well as the severity and
context of the boundary crossing or

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violation. Consequences may range from
verbal warnings to license

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suspension or revocation.

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So, how can we identify potential
boundary crossings and violations before

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they happen? Nurses who display one or
more of the following behaviors should

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examine their patient relationships for
possible boundary crossings or violations:

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excessive self-disclosure, secretive
behavior, special treatment, flirtation,

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or overprotective behavior. Any of these
behaviors may indicate a shift from the

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therapeutic nurse/patient relationship to
over-involvement with the patient. Once a

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nurse becomes over-involved in the
patient's world, the professional

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relationship is betrayed.

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Many of these behaviors
may have a reasonable

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explanation, however, if a pattern
emerges, it's time to stop and evaluate

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the behavior and possibly talk with a
colleague or mentor. The earlier a nurse

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evaluates behaviors and seeks help, the
greater the chances of returning to the

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therapeutic nurse/patient relationship.
Take the case of Katy, a nurse caring for

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a late stage cancer patient, Cindy.
Cindy's husband Joe is having trouble

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coping with his wife's illness. Wanting to
comfort Joe, Katy has drifted from

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conversations with him outside his wife's
room to having coffee with him in the

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hospital's cafeteria. Now, Joe is calling
Katy at home and posting comments on

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social media, saying she's the only person
who really understands what he's going

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through. Uncertain what to make of the
situation, Katy talks to her nurse manager

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who helps Katy understand that, while her
intentions are good, her actions

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constitute inappropriate over-involvement
with a patient's family.

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Because she is open to assessing her
professional relationships and sharing her

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concerns with her manager, Katy is able to
return to patient-centered care before a

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boundary violation occurs. If Katy hadn't
recognized the warning signs and talked to

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her manager, the crossing could have
escalated to a boundary violation.

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Boundary crossings can happen to any
nurse. The key to avoiding them is

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continual alertness, self evaluation and
emphasis on the patient's best interests.

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In respecting professional boundaries,
nurses protect their patients, themselves

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and the profession.