In professional relationships, individuals use expert knowledge to engage in purposeful relationships in which meeting the needs of clients is their goal Professional relationships are in contrast with social relationships, which do not assume expert knowledge by one of the participants and are not directed at meeting the needs of one of the parties at the exclusion of the needs of the other (Gallop, 1998). The essence of nursing practice makes it possible for nurses to become significant people in patients' Uves. The intimacy of caring actions, the need to humanize institutional environments, the potential for long-term relationships with patients and families, and care provided in less formal settings, such as patients' homes, can lead to role confusion and potentially threaten professional boundaries.
Boundaries are limits within professional relationships that allow for safe connections based on the needs of individuals (Peterson, 1992). Professional nursing involves applying theory and using critical thinking and discretionary judgment in conjunction with nurses' therapeutic use of self. Compliance with narrowly drawn policies or rules in the absence of thoughtful, critical judgment can hinder nurses' discretionary judgment. Concomitantly, vagueness or uncertainly concerning professional ethics and appropriate boundaries furnish inadequate guidance for nurses (Cameron, 1997). The responsibility of the nursing profession to educate nurses about professional ethics and appropriate boundaries (Weisberg & Puffin, 1995) and the ongoing presence of boundary violations observed and reported in various practice settings led the author to incorporate this content into students' learning experiences.
Discussions over a 2-year period with nursing students, nurses, and others active in health care delivery revealed that boundary violations are identified as professionals engaging in sexual relationships with patients, accepting expensive gifts or cash from patients, or disclosing personal information, such as a telephone number or address, to patients. These activities are validated in the literature. In particular, there has been increasing attention toward health professionals who have engaged in sexual misconduct with current or former patients. Efforts to collect pertinent data regarding sexual misconduct have occurred among psychiatrists, psychologists, and social workers (Borys & Pope, 1989; Gartrell, Herman, Olarte, Feldstein, & Localio, 1986; Getchman, 1989). The National Council of State Boards of Nursing reported that .06% of nursing discipline hearings in 1995 involved sexual misconduct cases.
Actions such as engaging in sexual activities with thente or stealing money from patients clearly constitute boundary violations (Minnesota Board of Nursing, 1996). The Minnesota Board of Nursing noted increasing reports of boundary violations that were not as clear as sexual activity or theft, such as adopting a former patient or helping a patient manage his or her finances. However, these actions do present violations. The author believes violations occur in subtle and ambiguous ways, often offering professionals the opportunity to evaluate behavior or interaction and intervene accordingly, providing they are aware of the possibility of a problem.
While engaged in educational experiences in the practice setting, students and health care professionals identified troublesome situations they perceived to be boundary violations. Selected examples describe the scope of situations presented. A senior nursing student related:
He [staff member] would sort of get to me when no one elee was around. He wanted to have lunch with me when rm at my next rotation, I'm really glad [the nurse] heard. I didn't know what to do.
Another student stated:
She [the patient] asked me where I lived. All of a sudden I just couldnt think. Never tell personal information was all I could think. So I said "We're not allowed to tell that and then I realized how stupid that was. This lady was about 85 and was so kind I think she was just chatting with me and I acted like a robot that couldnt think.
A nurse manager relayed an incident involving nursing staff:
[The nurse] started visiting the patient at her apartment and helping her get settled there. The patient became very dependent an the nurse arni then started calling her here. . .
Finally, an experienced nurse explained:
What happened was that I answered the patient when she asked me what I didnt like about my job. I could have told her something that would have answered and satisfied her, but I really got carried away, you know. I could feel the curtain dose between us. Our relationship was never quite the same. It was like she didnt quite trust me in the same way. . .
The frequency of such scenarios and the struggles observed among students presented compelling evidence that this issue merited attention in a systematic manner. What resulted was relatively simple to implement, took minimal time, and yielded markedly different responses from students who were, and will continue to be, confronted with threats to professional boundaries. The activity used with nursing students easily can be adapted to use with nursing staff in any patient care setting. The three steps of the activity are:
* Presenting potential areas for boundary violations and having students identify possible violations they have encountered within these areas.
* Directing students to observe both professional boundary violations and professional boundary reinforcement in the clinical setting.
* Providing students with opportunities to identify suggestions for maintaining professional boundaries in situations where boundary violations were observed.
Potential Areas for Boundary Violations
Initially, it was important to clarify with the students the areas in which boundary challenges may occur. Some violations were obvious, and others were ambiguous, but nevertheless significant in the uneasiness they elicited, which indicated the importance of clearly stating potential areas of difficulty. Clinical conferences offer a forum where content can be presented to students and then students can be encouraged to reflect on experiences they have encountered in which they were presented with these challenges.
Physical Contact Boundaries
The nurse-patient relationship frequently requires physical contact, but it is difficult for any health care professional to assess how another individual perceives touch. However, touch should be avoided with certain patients, including those who are psychotic and could perceive touch as a threat and those who have experienced abuse in their past. It is wise clinical practice to use touch with caution. Patients often are able to clearly tell the health care provider how they feel about touch and that information can be useful when physical contact is necessary or when the nurse believes it can be a comfort measure or source of reassurance.
Gift, Service, and Money Boundaries
Gift giving is often a source of controversy. Gifts can be given to reciprocate for provided care, to manipulate or change the quality of care or the nature of the nursepatient relationship, as a perceived obligation, or be given to an organization to acknowledge excellence of care (Morse, 1991). Many institutions or agencies have policies regarding gift giving and acceptance. Timing of gift giving and the motivation from which it occurs are important considerations in determining its acceptability.
Money boundaries are related to providing compensation for treatment Patients or families sometimes feel the need to offer extra compensation for assurance of care or improved care. Occasionally, patients or family will offer their services to the nurse. These situations require the nurse to carefully consider how to respond to these situations in a manner that maintains professional boundaries and the professional relationship.
Nurses' attire, whether in or out of uniform, should be appropriate for a professional In certain settings, limits may need to be set regarding patient attire. Current fashion may significantly influence guidelines for nursing students' attire, and it may be necessary to discuss the acceptability of certain attire, jewelry, or hairstyles in the professional health care environment.
Self-disclosure initially is a source of conflict. Students who are uncertain about whether they can disclose anything personal find themselves in troublesome situations when they encounter a patient or situation that reminds them of their own experiences. It is helpful to discuss and role play how students will respond when patients ask personal questions, such as "Where do you live?," "How old are you?," "Are you married?," "Do you drink (alcohol)?" and "Do you use (illegal) drugs?"
Role boundaries are essential to nurses' roles and often can be clarified by asking, "Is what I am doing what a nurse in this setting typically does?" When students feel uncomfortable, it is likely there is the potential for some role violation. Nurses in long-term relationships with patients and families and those involved in home-care situations are particularly vulnerable for boundary violations.
Language boundaries refer to the familiarity with which nurses speak to patients and the manner in which patients are addressed, in addition to nurses' choice of words m implementing care. There has been a trend to address patients by first names, often under the guise of protecting confidentiality. Students frequently are uncomfortable addressing persons older than themselves by first names and always are advised to ask patients how they would like to be addressed.
Space boundaries refer to where treatment occurs and how space is used. A general guideline is that treatment should occur in the space or location where it is intended to occur. Treatment in any other area must have a sound therapeutic rationale based on specific treatment goals. An additional consideration is how space is used within the treatment setting. This includes how nurses enter and use patients' space.
Time boundaries refer to conditions surrounding the time that muses implement interventions. In certain settings, time boundaries also may refer to time that is committed for a certain patient care activity.
Student Identification of Possible Boundary Violations
After the instructor presented areas of potential difficulty, students were asked to share situations they had found troublesome. They were reassured that each nurse has encountered these difficulties, and one of the first steps in learning to cope with these challenges is learning to recognize when they occur. Situations cited by students included:
* While working in home health, a student began doing a patient's laundry on a weekly basis. The patient then gave the case manager a gift for the student in gratitude for her help. The student was strongly reprimanded and torn between doing what she believed was the "right thing to do" and complying with the agency policy.
* A family member offered a student $20 to "take good care" of a parent.
* A patient's spouse offered the student a job in another field.
* A student met a former patient for lunch.
* A health care provider was checking a patient's blood pressure while sitting on the bed with the patient and just seemed too close.
These selected examples illustrate the students were able to identify situations they had observed and also times when they believed a health care provider violated professional boundaries when the students were in the patient role. When students presented these scenarios, they were asked how they believed the situations should have been handled.
Following this phase of discussion, students were presented with a written assignment They were to be attentive to situations in the clinical area where professional boundaries were both violated and reinforced. Students were assigned to briefly describe three situations and how nurses responded to them.
Student Observations of Boundary Violations or Reinforcement
Students were able to identify examples of boundary violations and reinforcement. The following are students' examples of boundary reinforcement:
* Once a patient was in the dayroom with a shirt that ehowed her midriff. TTiis was a clothing boundary violation The nurse asked her to change her shirt, which she did.
* One nurse set a limit en a patient during group session. The patient would constantly interrupt whoever was speaking. Other patients were getting frustrated and a couple of patients tried to leave. At first the nurse gently tried to stop the patient, but then the nurse got firmer and told the patient the session was to continue without constant interruptions from her. It fortunately worked.
* I was making rounds and this one patient was following me, breathing right down my neck I wasn't really worried because I was out in the open, but one of the nurses came and told him he was too close to me. I actually was very relieved.
* I was on a visit with a home health nurse. The patient wanted the nurse to go get her medication for her. She offered her quite a bit of money to do it. The nurse said something like she couldnt get her the medication, but she would find a way that the patient could get her medication I was nervous because the patient was very upset. The nurse was very kind, but responded firmly that she could not do that The patient then said she could pay her whatever it would cost for her to do it The nurse again explained that she would help the patient find a way to get her medication, and she did it while we were there. It was actually easier than I thought.
* A patient was having some tests and decided he wanted to go home against medical advice. He was so furious he started using foul language with the caregivers. The charge nurse told him his language was not acceptable and would not be tolerated.
Examples of observed boundary violations in which the students' suggested responding differently included:
* One nurse developed a close relationship with a patient, and I overheard her talking about the divorce she was going through. She was going into a lot of detail I thought that violates self-disclosure. I dont think you should talk about personal things with patients.
* I was helping a nurse with a patient He kept saying things to her like, 1Yi)U1Te cute,' 'Are you married?' and TJo you have a boyfriend?' The nurse just ignored him. She should have said something to stop him.
* An elderly male patient was sitting in his chair. A nurse began taHrfpg to him and she placed her hand on his shoulder. The patient however, pushed her hand away. Physical contact in this instance, should have been limited, and the nurse should not have placed her hand on him.
* A nurse was helping position a patient when the patient's roommate asked the nurse a question. The nurse exclaimed, 'Can't you see Tm busy? Just wait! ' This was an inappropriate tone of speaking and choice of words to use toward a patient.
* Due to the poverty that many of the patients live in, they do not have much in terms of toys and books. Often staff members buy toys, books, and calculators for these kids. It seems innocent and caring, but sometimes it causes problems or hurt feelings, and it still is boundary violation. It is sad, but it really is not the nurse's job to buy gifts like this. . .
An area that frequently merits considerable discussion is when it may be possible to accept gifts from patients. Students are reminded to be aware of the policy in thenworkplace and, if the gift does not violate that policy, to consider the timing and intent of the gift. Occasionally, during discussion, students will find gift giving unacceptable, when, in fact, it seems to be solely an act of gratitude that may be considered reasonable in its intent.
What has occurred in all discussions is that students are distinctly more aware of potential threats to professional boundaries and more confident in their ability to assess and respond to those situations. It has been important to say to them, "Do not tell me what you would do- tell me precisely in your words what you will say." Providing actual responses forces students to identify exactly what their words will be and provides them with practice. An exercise involving a relatively neutral question is identifying students' responses to "Where do you live?" It is useful for students to identify their responses and observe that there can be several acceptable ways of responding. Participants in sudi an exercise may be provided with suggestions and guidance. However, each student has to use knowledge, their own language, and individual therapeutic use of self to respond in a manner that will be effective and subsequently strengthen and affirm their relationships with patients.
Beginning and experienced health care providers will encounter situations that threaten professional boundaries. I /taming to recognize these circumstances and respond in a professional manner may prevent potentially unsafe occurrences, while strengthening the nurse-patient relationship and enhancing opportunities for therapeutic interventions.
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- Getchman, L. (1989). Sexual contact between social workers and their clients. In G. Gabbani (Ed.), Sexual exploitation in professional relationships (pp. 27-38). Washington, DC: American Psychiatric Association.
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