Journal of Nursing Education

Major Article 

Educator or Counselor? Navigating Uncertain Boundaries in the Clinical Environment

Annette M. Lane, PhD, RN; Lynn Corcoran, MN, RN

Abstract

Background:

Nurse educators in the clinical environment experience great rewards and challenges in their work with undergraduate students. However, closely working with students can lead to the challenge of intervening with those who are emotionally distressed. How do nurse educators navigate the precarious and subtle territory between educating and counseling?

Method:

This article briefly reviews how boundaries are explored in nursing. Two case studies are presented to demonstrate how nurse educators can determine when their support and education begins to move into the counseling role. Finally, future directions for nurse educators are suggested.

Results:

Little research exists that examines how nurse educators navigate the boundaries between educator and counselor roles with students in clinical settings.

Conclusion:

Navigating between the educator and counselor roles with students experiencing emotional distress in clinical settings can be challenging for nurse educators. [J Nurs Educ. 2016;55(4):189–195.]

Abstract

Background:

Nurse educators in the clinical environment experience great rewards and challenges in their work with undergraduate students. However, closely working with students can lead to the challenge of intervening with those who are emotionally distressed. How do nurse educators navigate the precarious and subtle territory between educating and counseling?

Method:

This article briefly reviews how boundaries are explored in nursing. Two case studies are presented to demonstrate how nurse educators can determine when their support and education begins to move into the counseling role. Finally, future directions for nurse educators are suggested.

Results:

Little research exists that examines how nurse educators navigate the boundaries between educator and counselor roles with students in clinical settings.

Conclusion:

Navigating between the educator and counselor roles with students experiencing emotional distress in clinical settings can be challenging for nurse educators. [J Nurs Educ. 2016;55(4):189–195.]

Nurse educators in the clinical environment experience great rewards and significant challenges. Some of the rewards of teaching in clinical settings involve working with smaller numbers of students, helping them to convert their knowledge into direct work with patients who are often very ill, and sometimes helping them to develop strategies to manage the stresses and tensions in the clinical environment. However, the same aspects of teaching in clinical settings that are rewarding can also pose significant and precarious challenges. For instance, through helping students to address their reactions to acutely ill patients and their families, they often reveal their own personal struggles. Although clinical education can involve helping students examine how their life experiences impact their abilities to provide care for patients and families, nurse educators are often left with difficult questions. At what point does educating students move into the realm of significant counseling? Also, if nurse educators sense that they are counseling a struggling student, what can they do to recognize and address this? Addressing those questions is important because if nurse educators move heavily into the counselor role, they may be unable to exercise sound judgment when deciding whether students should pass or fail the clinical course. When this occurs, the educator assumes too much responsibility and subsequently takes on too much stress. (Note. Throughout this article, the term counselor is used to refer to the counseling tasks of nurses). This term is used for simplicity purposes and to avoid the unwieldy term of nurse counselor. However, the authors are specifically referring to the counseling aspects of nursing and not to the actual profession of counseling. Further, the authors are specifically referring to those times when counseling becomes extensive enough for the educator to experience difficulty evaluating the student.)

This article offers a brief review of how boundaries are discussed in the nursing literature. In particular, the authors examined the literature that addresses the challenges of the boundaries between educating students and counseling them. Two case studies of students encountering difficulties in the clinical environment are presented as a springboard to discuss what the notion of boundaries involves and why nurse educators can struggle when navigating these educator–counselor boundaries with students experiencing difficulty in the clinical environment. Finally, the authors present principles that may guide nurse educators when working with students who are struggling.

Literature Review

To evaluate the boundaries between educating and counseling students in the clinical environment, the authors conducted a literature search using the CINAHL® database. Search terms included combinations of the following: boundary, boundaries, nursing, nursing student(s), nursing instructor(s), nursing education, clinical, and clinical practice. Most of the published literature appears to focus on boundaries in the therapeutic nurse–patient or therapist–client relationship (Austin, Bergum, Nuttgens, & Peternelj-Taylor, 2006; Baca, 2009, 2011; O'Lynn & Krautscheid, 2011; Peternelj-Taylor & Yonge 2003; Shepherd, 2013, 2014). In the literature, the focus is often on the boundaries of relationships with patients (i.e., personal relationships versus professional relationships), as well as personal communication (e.g., the nurse not sharing too much personal information with patients), or around the use of touch. Further, the literature often makes the distinction between boundary crossing (less serious) and boundary violation (more serious direct breaches of the professional–client relationship; Austin et al., 2006). Of note, the National League for Nursing's Nurse Educator Core Competencies (Halstead, 2007) includes competency #2—Facilitate Learner Development and Socialization—that opens up space for nurse educators to engage in some degree of counseling of students to facilitate learning.

Interestingly, a subset of literature now focuses on the use of social media by nurses and nursing students and the boundaries around its usage (Nyangeni, Du Rand, & Van Rooyen, 2015; Peate, 2013; Stott, 2015; Wylie, 2014). Recognizing the precariousness of social media, national and international regulatory bodies (e.g., American Nurses Association, Canadian Nurses Association, International Council of Nurses) are advising nurses on maintaining boundaries. The American Nurses Association (2015) has a comprehensive online toolkit consisting of a webinar and a fact sheet, as well as a tip card and a poster, outlining six basic principles of social networking and six suggestions regarding how to avoid problems. The Canadian Nurses Association (2012) devoted an entire issue of Ethics in Practice for Registered Nurses to ethics, social media, and nurses and nursing. In that publication, the types of social media are defined, followed by five relevant practice-based vignettes designed to initiate conversations about norms and etiquette, as well as the challenges and opportunities of social media use. The importance of patient confidentiality and privacy are also highlighted. The International Council of Nurses (2015) published a detailed position statement titled Nurses and Social Media. The responsible use of social media by nurses, as well as the potential risks and benefits, are included in that position statement.

A conspicuous dearth of literature exists that addresses the boundaries between clinical nurse educators and students. A notable exception was the research of Zieber and Hagen (2009). Using a qualitative approach, they interviewed eight nurse educators about boundaries with students in the clinical environment. They reported that the clinical educators believed that observing boundaries is different in the clinical environment than in the classroom, in part because of the intense emotions evoked by patient situations. Clinical educators described boundaries as being fluid and flexible in the clinical environment, somewhat time determined (the longer the clinical rotation, the more relaxed the boundaries become over time), and involving issues of self-disclosure with students, as well as personal touch. Although sexual touch was clearly taboo, some touch was appropriate in the clinical environment; male educators exercised greater caution regarding the physical distance between themselves and students, including less touch. Self-disclosure was a more contentious issue. Educators noted that self-disclosure of experiences as students and nurses was key in educating students; however, they emphasized that intents were important when sharing with students. Self-disclosure was to benefit students' learning, rather than the educator (Zieber & Hagen, 2009).

It was difficult to specifically locate relevant, scholarly literature examining or describing the blurring of boundaries between the roles of the nurse educator and counselor in relation to nursing students in clinical practice settings. The blurring of lines between roles appears to be an unexplored area in nursing research, which potentially could be problematic, as providing counsel to students in the clinical environment may impede the educator's sound clinical judgment regarding the passing or failing of the struggling student. Although it is recognized that some degree of counseling support can occur in the clinical environment, too much counseling can become problematic for the educator and clinical evaluator. This article presents two clinical exemplars of students encountering difficulties in the clinical environment to demonstrate the principles and guidelines in navigating boundaries between counselor and educator.

Exemplars

Clinical Exemplar #1: Mental Illness in Mental Health Nursing

Erin is a 21-year-old student who is now in her mental health clinical rotation. She is working in a psychiatric unit. She has arrived late to the clinical site twice thus far, appears shy and afraid to engage patients, and avoids assessing patients for suicidal ideation. When you take her aside to debrief a one-to-one interaction with a patient, she tears up. She admits that she is currently taking an antidepressant medication and that her cousin recently committed suicide. She confesses that she is unable to assess her patients for suicide because this topic “hits too close to home.” As an initial response, you speak to Erin about safe, competent, and ethical practice in the context of self-regulation and determining one's fitness to practice. It is Friday afternoon, so you also discuss self-care strategies with Erin, such as getting adequate sleep and rest, drinking plenty of water, eating healthy foods, going for a walk, talking to a close friend or family member, and doing an activity that she enjoys.

As with all students in this mental health rotation, Erin has your mobile telephone number. You have instructed all students to send you a text message at least 1 hour prior to the beginning of their shift if they are unable to attend their scheduled clinical day. In addition, you have instructed the students to use your mobile telephone number to contact you outside the hours of this clinical rotation in case of a personal emergency that may impact their attendance or clinical performance. Upon waking and checking your telephone on Saturday morning, you see that you received eight text messages from Erin between the hours of midnight and 2 A.M. The content of Erin's text messages range from thanking you for your support and kindness to asking you questions about what she can do to be more successful in this clinical rotation. Later in the day, you check your Facebook® account and see that Erin has sent you a Friend request. As the clinical educator, you wonder how you should respond or, especially, how you should not respond.

Clinical Exemplar #2: When Personal Beliefs Clash With Professional Responsibilities

Janet is a 26-year-old nursing student in a 4-week community health clinical practicum working alongside an experienced public health nurse preceptor. The area in which she is practicing is a community health clinic in a large urban center. Her primary responsibility is to provide care in the Well Child Clinic, which includes assessing infants, toddlers, and preschoolers related to their growth and development, as well as educating parents regarding vaccinations for their child, and, with consent, administering these vaccinations. Although Janet is competent with introducing herself to the families in the clinic and weighing and measuring babies and children, Janet's preceptor reports to you at mid-term that Janet is reluctant with all aspects of education on vaccination and the administration of vaccines.

As Janet's clinical educator, you share this perception with her at the mid-term evaluation. Janet starts to cry. She tells you that she has two children, does not believe in vaccines or vaccination, and has not vaccinated her children, and that it is inordinately difficult for her to be in this clinical rotation. She goes on to share with you her many life stresses, including difficulties with child care, problems with her relationship with her husband, and pressures from the student financial aid department regarding payment of tuition. As the clinical educator, you wonder how you should respond, or, especially, how you should not respond.

Exemplar Summary

The two clinical exemplars presented differ in that in Erin's situation, the supervision was more direct than in Janet's situation. However, the situations were similar in that each student was in significant distress, and the distress significantly impacted the student's ability to provide safe patient/client care. Also, each nurse educator was faced with the challenge of how to help the student. The nurse educators had to explore the students' life experiences to ascertain the barriers that prevented the students from providing safe care; yet, how much information should they seek or how deeply should those instructors inquire about the life experiences of their students? Also, at what point do the educators collect too much information or provide too much support, where they are acting more as counselors than as the educators who will evaluate student performance? These questions are not easily answered.

The authors will first address why educators struggle with boundaries between the educator and counselor roles within clinical settings and then will offer some guidelines and principles that can help educators to navigate this thorny realm. Throughout the Discussion, the authors will refer to the case exemplars of Erin and Janet.

The Struggle with Boundaries Related to Balancing the Nurse Educator and Counselor Roles

Various reasons exist as to why instructors wrestle with boundaries delineating the nurse educator role from the counselor role when working with students struggling in the clinical environment. These reasons relate to the operationalization of a theoretical concept such as that of boundaries, as well as varying contexts related to the student, the clinical environment, and oneself as a clinical educator. Also, operationalizing boundaries in relation to students in clinical settings often results in dilemmas. When situations involve dilemmas, struggle ensues because two (or more) compelling choices exist. Although policy is in place to guide practice and provide direction for dilemmas, rarely does policy substantively assist with resolving such dilemmas. Often, these dilemmas have gone beyond the bounds of policy and are outside the clarity provided by policy.

Operationalizing a Theoretical Concept

In general, the term boundary signifies “something that indicates a border or limit” (“Boundary,” n.d.). However, this definition does not help us understand how boundaries are conceptualized within relationships. In interpersonal relationships, the term boundaries “refer to the rules that establish the professional relationships as primary and as separate from other relationships” (Owen & Zwahr-Castro, 2007, p. 117) or, as noted by Austin et al. (2006), what is “out of bounds” in relationships (p. 77). Although those definitions apply to interpersonal boundaries, they fail to bring clarity to the many complexities faced by professionals in their helping relationships with students or clients. Also, in the complex and highly charged emotional environment of clinical environments, the definitions do not offer guidance for how nurse educators can operationalize boundaries with students. Although the term boundaries denotes restrictions (Austin et al., 2006), what is to be restricted remains fuzzy and unclear; truly, boundaries can be a moving target!

Further, in operationalizing boundaries, hard and fast rules often do not work, as the contexts in which to observe the boundaries can vary dramatically or, sometimes equally perplexingly, subtly. Therefore, taking into account all kinds of contextual factors (the student, ourselves as educators, and the acuity of the clinical environment) will result in many permutations and combinations of what is acceptable at times and unacceptable at other times.

The Student

Students come into nursing with varied life experiences that can trigger struggles in clinical practice. Childhood abuse, poverty, illness or death of family members, and war or famine (for students who come from countries mired in conflict or those experiencing scarcity) can trigger emotional reactions when providing care to patients who have experienced similar situations. Some students may cry, express their childhood experiences to the nurse educator, and then, with admirable resilience, press on to not only complete the clinical rotation but to do so with strength, humor, and even excellence. However, others may struggle. Such students' emotional responses can be so strong that they slide into emotional paralysis. In those situations, the nurse educator may be walking a tight rope to support the student, not leaning over too extensively to the side of counselor, thereby negating his or her ability to fairly evaluate the student. Similarly, some students may not have experienced significant childhood trauma but may currently be facing traumatic events, such as experiencing their own serious health challenges, breakups with partners, untimely deaths of family members, or financial pressures, and are overwhelmed by these circumstances. In those situations, the nurse educator may feel extra pressure to support the student, as the student's emotional reactions are due to current challenges, rather than lifelong challenges.

Further, students vary in the type of support they would like or need. Some students may find self-disclosure of nurse educators in the clinical environment to be most helpful, whereas others may not. Although the nurse educator may be clear on his or her intent regarding sharing, the student might potentially conceptualize the disclosure as signifying that the relationship has moved to a personal or friendship level. As noted by Owen and Zwahr-Castro (2007), students may view the nurse educator's friendship as inappropriate. Or, students may welcome the perceived friendship and, as in the case of Erin, engage the instructor with multiple text messages outside the boundaries set by the instructor or seek to “friend” the instructor on Facebook.

In coping with the emotional responses or life experiences of students, nurse educators are caught in the blurry boundaries of their current position, compared with past positions. Nurse educators are still nurses, but their students are not patients. Nurse educators may believe that they would know how to respond if these students were patients but wonder how to react due to their educator role. Further, if the nurse educators are relatively new in their positions, they may impulsively lean toward the more comfortable role—that of a nurse. In Zieber's and Hagen's (2009) study, nurse educators noted that as nurses they had no problems with hugging patients; however, in their role as educator, they knew they had to be more careful with touch. Not only might the nurse educators be unclear about the expectations of their educational institution, but they may also wonder how much support they can give to these students without sliding into the counselor role; as nurses, they had greater latitude in terms of offering emotional support and, at times, even using general counseling techniques. However, as clinical nurse educators they instinctively recognize that there is a difference between patients and students and that their role is different as an educator than as a nurse. Educators may honestly ask, “How and when do I determine that I have moved beyond educational support into a nurse/patient counseling role? What do I look for and how do I avoid becoming too supportive of the student? If I determine at some point that I have gone too far in my support, is this my fault or is it my fault if I do not try hard enough to support the student?

Ourselves as Individuals and Educators

Not only do educators navigate blurry boundaries between educating and counseling struggling students, they also bring into their work their own life experiences. Educators who were raised in homes with strict boundaries, particularly around emotional expression and self-disclosure, may be uncomfortable with the fluidity of boundaries between themselves and students in the clinical environment. For instance, in the example involving Erin, a nurse educator who was raised in a home where crying was not acknowledged and emotions were not discussed may feel that he or she has to respond to Erin, but he or she may also feel it is being too intrusive to ask Erin whether she is experiencing suicidal ideation. The educator's belief and comfort in adhering to boundaries regarding emotions and expression of distress may impact his or her ability to respond therapeutically to Erin. Conversely, a nurse educator who was raised in a home with loose boundaries, may feel comfortable with Erin's expressions of distress but he or she may be less aware of when the boundary to counselor is crossed or when he or she has functioned as a counselor for too long. The educator may also be less aware when the relationship has moved from the educator–student role to a friendship role and thus may not clearly recognize that Erin has begun to conceptualize her as a peer, as evidenced by the multiple texts in the middle of the night and a Facebook friend invitation.

Acuity of the Clinical Environment

The ability of nurse educators to allow struggling students to continue in a clinical environment is also related to the acuity of the placement. If the unit or clinical placement is highly acute with very ill patients, the educator may determine that the student cannot focus on patient care due to his or her overwhelming emotional issues. Similarly, the educator may feel that the close supervision required to ensure student safety is not possible, as the educator's attention may be divided between eight students across two or three units. In such situations, the educator may determine that supporting the student is not possible. Further, it may be less complex to navigate between the counselor and educator roles, as the clinical context may dictate removing the student from the environment.

For example, in the Well Child Clinic (Janet's) example, if the environment is busy and staff are overextended, the preceptor may not be able to spend the time required to cover his or her own tasks, as well as assuming the work that Janet is supposed to be completing. The preceptor may not be able to trust that Janet will provide the necessary education to the parents and their children and that she may not follow through with administering vaccinations, even when she is aware that this is what the work of the nurse entails. Further, the preceptor may feel upset and angry that he or she has to be mindful of the emotions and beliefs of a student when the workload is overwhelming.

Underlying Principles to Guide Nurse Educators

Although no hard and fast rules exist for nurse educators to manage and monitor boundaries with their students in the clinical setting, there are principles that can guide their thinking and practice. Nurse educators should be aware of the National Council of State Boards of Nursing's (2014) publication on boundaries, as well as to consider the guidelines mentioned below. These principles may help nurse educators to wade through various dilemmas and to understand why they feel challenged and conflicted.

The Safety of Patients and Students Is Paramount

In considering the role of educating students, the safety of patients, as well as the students, should be paramount. Although most, if not all, nurse educators would offer their full intellectual assent to this principle, enacting this may not be as simple. Why might this be? Nurse educators are well aware of the challenges that students have in adjusting to the stresses of providing care to very ill patients within fast-paced clinical environments (Alzayyat & Al-Gamal, 2014; Galvin, Suominen, Morgan, O'Connell, & Smith, 2015). They may genuinely empathize with their students' trials in the health care environment and thus may want to do everything they can to ensure the students' success, even if it involves an inordinate amount of time and energy to emotionally support the students. The educator should be aware of when the role of supporting the student slides into a significant counseling role. This important differentiation needs to be honored and prioritized by leaders in nursing faculties. Thus, with the example of Erin, the educator needs to consider whether the safety of the patients in the unit is being jeopardized by Erin's emotional state and her inability to assess for suicidal ideation in her patients. Also, what about Erin's mental state? Is the depressed state of her patients causing her to deteriorate mentally, thereby potentially endangering her safety? If either the patient or the student is unsafe, then extraordinary efforts to support and bolster a student is unwise, despite the admirable intent of the nurse educator. Consideration of these questions may assist the clinical educator in gaining self-awareness about whether his or her support is facilitative of Erin's growth (as evidenced by Erin's improved mental state and ability to provide safe patient care) or, conversely, that it is not helpful in ameliorating Erin's distress.

Is the Student Able to Proceed After an Initial Discussion?

In the initial discussion, when students expose their painful experiences or the disparities between their personal beliefs and health care practices, nurse educators can strategize with students about how they can manage the pain or the disconnect between their personal beliefs and their nursing responsibilities. Thus, the nurse educator working with Erin might offer some guidance on how she will know when she is not coping (e.g., being unable to set the day's experiences aside when going home, having nightmares, feeling distressed and depressed, being unable to explore suicidal ideation with patients), as well as some strategies on how to cope with her stress and manage clinical situations (e.g., seek counseling from her educational institution, see her doctor, exercise, engage in journaling). Certainly, the educator needs to reset the boundaries with Erin regarding the use of texting in the context of the clinical rotation. In addition, it is important for the educator to have an open discussion with Erin about social media use in general and about the Facebook friend request in particular.

Regarding Janet, the nurse educator would explore the rationale for Janet's beliefs, offer facts about vaccinations that may challenge her beliefs, and explain the responsibilities of this clinical rotation, including the expectations regarding education about and the administration of vaccines. The educator would also explore with Janet her options for this clinical rotation and the consequences if she does not meet the responsibilities of the rotation.

After an initial discussion with the nurse educator, some students feel a sense of relief in speaking about their painful life experiences (as in Erin's case) or their differing health care beliefs (like Janet) and are able to proceed competently. Somehow unburdening themselves, knowing that the nurse educator is aware of their challenges and having a concrete plan to move forward, engenders courage. These students may go on to practice competently and truly soar as they challenge their personal beliefs and what they are capable of achieving. For other students, the grief, pain, and disconnect (between what they need to do and what they are actually able to do) becomes too much. They may continue to cry in the clinical setting, experience an emotional paralysis when called on to act in challenging ways (such as conduct suicide risk assessments or administer vaccinations), and be unable to move forward in their thinking and actions. The inability to move forward after the initial discussion may be an indicator that the nurse educator will be pulled into the counselor role if the student continues in the clinical rotation; therefore, the student may need to consider withdrawal from the situation to avoid failure.

What Is the Workload Associated With Supporting Students?

When nurse educators are working with a struggling student in a clinical rotation, they need to consider the work involved for one student in relation to the remainder of the students in the clinical group. For instance, if the nurse educator finds that a student, such as Erin or Janet, is consuming 50% of his or her time in the clinical setting, then the other students in the clinical group would have to share the remaining 50%. Thus, each student receives a smaller fraction of the educator's time, energy, attention, and expertise. Erin or Janet would consume far more of the educator's time than the other students, which, it could be argued, is not fair to the other students. However, most nurse educators invest more time than the standard 8 hours in a clinical shift. As such, these nurse educators may spend time before, during, and after a shift talking with Erin or Janet, debriefing their patient/client interactions, strategizing about ways to move forward, and, overall, expending physical and emotional energy. In addition, these nurse educators may have to stay late in the clinical site to seek feedback from staff regarding the performance of Erin or Janet, calling the course coordinator to discuss their concerns, drafting learning or behavioral contracts, documenting anecdotal notes, and worrying about the student's safety and that of her patients or clients. The basic math regarding the time spent, as well as the sheer enormity of these extra emotional and physical activities, may indicate that the nurse educator has moved more into the counselor role.

What Supports Do Nurse Educators Need?

This question, although related to the amount of work and energy being expended, is somewhat different. When the nurse educator is feeling the need for emotional support, it may be an indicator that the educator has drifted toward the counselor role. Why do the authors suggest this? Buttressing an emotionally distraught student, particularly when expending a great deal of energy and attention to the student's performance and patient/client safety, is tremendously draining. The nurse educator may need to find reinforcement and support to maintain his or her professional judgment, to wade through conflicted emotions, and to make decisions regarding the success or failure of the student. The nurse educator may experience feelings of being stressed, overwhelmed, and even frightened (e.g., if the student has to withdraw or earns a failing grade, it might this push the student to a mental breakdown). These feelings are strong indicators that the nurse educator has been pulled into the counselor role and, indeed, has experienced some personal trauma in the process.

Weighing the Immediate Situation With Long-Term Consequences

Many nurse educators use a strengths-oriented paradigm with students; that is, they view students as possessing strengths and having the ability to learn and grow professionally. Many also exhibit great compassion for students, understanding the challenges faced by students juggling academic demands, coping with life's vicissitudes, learning to care for ill patients, and coping with the fast-paced health care environment. As such, educators may choose to err on the side of extending grace toward struggling students. Although this approach is admirable and even fair, if students such as Erin and Janet continue unsuccessfully, then nurse educators may need to weigh the immediate situation with the potential long-term consequences. For instance, if Janet is not able to cope existentially when her beliefs differ from those of the majority of health care providers and she is not coping with the stresses of her education on her marriage and family life, then giving Janet a passing grade may not be the most compassionate decision. In the immediate situation, Janet may be placated and calmed, but in the long term, she may encounter similar trials that result in failure. Janet may then wish that her nurse educator had suggested a temporary withdrawal from the nursing program (to consider her options) or even had failed her. Not only will Janet have paid more money toward an education that appears to be a poor fit career-wise, but also the demands of education may result in further deterioration of her family life. Although the nurse educator is not responsible for the impact of nursing education on Janet's emotional health and her marriage and family life, it is worthwhile to note that compassion actually may be not that compassionate.

Discussion and Future Directions

By attempting to delineate between the educator and counselor roles in clinical situations, the authors are not suggesting that educators commit serious violations in this regard. In fact, as noted previously, some degree of counseling as it pertains to learning can be useful. However, the authors posit that the difference between counseling to illuminate students' learning versus encouraging them emotionally can be subtle at first but then may lead to a difficult and emotionally heavy burden for the nurse educator. Although this boundary crossing of providing extensive emotional support is committed with the best of intentions for the students, the slide into a counselor role is hard on nurse educators and places too much responsibility on them.

Further, the purpose of this article is not to provide hard and fast rules for the educator, as there are no concrete rules. In fact, Austin et al. (2006) proposed that the ethics of behaviors in helping relationships may be conceptualized as a territory, rather than as a boundary. This may open space to understand the flexibility and fluidity of boundaries and to recognize that sometimes attending to the relationship (i.e., between the student and nurse educator) is far more therapeutic and powerful than clinging to decrees about how to respond. That being said, the authors suggest that within the vastness of the relationships territory in the clinical environment, nurse educators should be mindful of the principles that guide their ethical behaviors with students, as well as to consult documents such as the National Council of State Boards of Nursing's (2014) guide to professional boundaries. Not only will this help nurse educators to avoid behavioral missteps with students but it may help them to feel less tension around how to help students without crossing boundaries.

Also, the authors propose that nurse educators, as well as nursing education programs, need to recognize when educators are working too hard to maintain struggling students in clinical courses, particularly when the emotional and mental health challenges prevent the students from providing safe care to patients and families, when the work involved takes too much time away from other students, or when nurse educators experience distress in the process of supporting such students. Although this support is important for all educators, regardless of how long they have taught clinically, it is imperative for new clinical educators who may not know how to navigate between the educator and counselor roles. Orientation that includes a discussion of boundaries, as well as ongoing mentoring or support, is vital.

Finally, exploring how nurse educators navigate boundaries, or territories, in relation to educating students in the clinical environment, appears to be an unexplored area. The authors propose the need for research exploring how nurse educators and students within the clinical environment perceive the work of educators in pressure-packed situations and what behaviors are viewed as helpful and therapeutic and what are not.

Conclusion

Nurse educators working with undergraduate nursing students in clinical settings face significant challenges when students experience emotional distress as a result of providing nursing care to patients and their families. Although a nurse educator's primary role related to nursing students is teaching and learning, the subtle shift to the role of counselor can and does occur when a student discloses personal details regarding emotional reactions or distress around a particular situation with a patient or family members. Recognition of when the boundary between educator and counselor is becoming blurred or is being crossed is an initial step for nurse educators. Future research in this area would help guide nurse educators in this regard, with the added effect of benefiting nursing students.

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Authors

Dr. Lane is Associate Professor, and Ms. Corcoran is Program Director, Bachelor of Nursing Curriculum & Regulatory Affairs, Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, Canada.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Annette M. Lane, PhD, RN, Associate Professor, Faculty of Health Disciplines, Athabasca University, 1 University Drive, Athabasca, Alberta T9S-3A3, Canada; e-mail: alane@athabascau.ca.

Received: October 27, 2015

Accepted: January 20, 2016

10.3928/01484834-20160316-02

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