Nurses identify difficulties with professional boundaries in the nurse–patient relationship as a common ethical dilemma (American Nurses Association [ANA], 2010; Cecil & Glass, 2015). In mental health clinical settings, the therapeutic nurse–patient relationship provides the basis for effective caregiving and treatment. The relationship is dynamic and goal-oriented and involves boundaries that create a foundation for trust, safety, and reliability; boundaries prevent abuse of power and ensure the nurse acts to safeguard the patient's welfare (National Council of State Boards of Nursing, 2014; Peternelj-Taylor, 2002). Boundaries are the mutually understood physical, emotional, sexual, and social limits of a relationship. The nurse's clinical knowledge and expertise should serve the patient's best interests (Peternelj-Taylor, 2002). In this relationship, nurses have more power and knowledge, which typically places the patient in a more vulnerable position. When patients offer romance or gifts, ask for special favors or for nurses to keep a secret that challenges boundaries, they can create an ethical dilemma for nurses who want to respond therapeutically.
The Nurse–Patient Relationship
ANA (2010) standards require RNs to maintain a therapeutic and professional patient–nurse relationship with appropriate professional role boundaries. Nurses want to avoid under- and over-involvement in their relationships with patients. For example, a new patient entering the psychiatric emergency department complaining of sexual abuse, who is frightened of going home alone, may ask the nurse for a ride home, and the nurse wonders whether offering a ride home would be considered over-involvement and overstepping a professional boundary. Overstepping of boundaries can harm the nurse–patient relationship and the patient can interpret this action as “friendship” rather than a professional relationship. Some boundaries are clear and distinct, whereas others require nurses to evaluate the situation using professional judgment.
Parameters for the nurse–patient relationship include a defined professional role, confidentiality of information, and a time limit for hospitalization, care, or treatment. Boundary violations occur when nurses overstep the accepted practice guidelines and potentially place the patient's welfare, caregiving, or treatment at risk. Common professional boundary violations include sexual and non-sexual boundaries, dual relationships, favoritism, gifts, self-disclosure, secretive behavior, over involvement, conflict of interest, and social media (Manfrin-Ledet, Porche, & Eymard, 2015). Maintaining professional boundaries protects patients' trust, ensures nurses' objectivity, and prevents risk of harm to patients (National Council of State Boards of Nursing, 2014; Peternelj-Taylor, 2002). Other boundary violations include inappropriate comments, intimate touching, and sexual intercourse (Chiarella & Adrian, 2014; Jones, Fitzpatrick, & Drake, 2008). Because patients in psychiatric settings have often experienced being controlled and ignored, they may learn survival strategies and tempt nurses to violate boundaries (Harris, 2014; Townsend, 2015). Patients may wish to ignore boundaries to gain favors, and may use defenses such as splitting (i.e., dividing and pitting nurses against each other) and projection (i.e., patients project their unwanted feelings onto others) (Townsend, 2015).
Characteristics of the Professional Therapeutic Nurse–Patient Relationship
Professional standards set the requirements and expectations of nursing practice (ANA, 2010; National Council of State Boards of Nursing, 2014; Townsend, 2015). The professional nurse–patient relationship has a specific phase, is goal-oriented and time-limited, and helps provide corrective and healthy interactions with patients (Ashton, 2015; Peplau, 1997). This relationship requires an appropriate use of authority and occurs within boundaries that differentiate professional and therapeutic behavior from non-professional and non-therapeutic behavior. Interactions occur in psychological, spiritual, and other realms that focus on patients' needs and not nurses' needs (Shattell, Andes, & Thomas, 2008). Nurses work with patients to encourage healthy behaviors and avoid boundary violations (Corbett & Williams, 2014; Jones et al., 2008). If nurses complain to patients about their private lives, look for sympathy, or speak poorly about colleagues with the goal of obtaining patients' compassion, then the behavior is for the nurses' gain and violates a boundary.
Nurses must consistently set and communicate boundaries (Table 1). Sometimes setting and communicating boundaries is simple: nurses may tell the patient, “We do not hit objects or people here,” “Space between us needs to be at least 2 feet,” or “You can't call me honey baby; call me Judith or Ms. S.” If the patient touches or crowds the nurse, the nurse tells the patient to stop touching or crowding. Practice settings challenge nurses to contemplate what boundaries mean personally and professionally (National Council of State Boards of Nursing, 2014; Peternelj-Taylor, 2002).
Examples of Professional Boundary Violations
Education About Boundaries
Professional boundary content and issues must be discussed in unit orientation or in-service education. Typically nurses are oriented to unit expectations and nursing, ethical, and hospital policy standards regarding gift giving, confidentiality, and nurse–patient relationship boundaries (e.g., sharing personal information, dual relationships, intimate sexual behaviors, substance abuse) (Table 2) (ANA, 2010; National Council of State Boards of Nursing, 2014). Examining boundaries may also occur in annual mandatory training, preceptor instruction, case conferences, huddles, and organizational policies. Potential boundary ruptures include friendships, sexual interactions, sharing personal information, dual relationships, keeping secrets, financial relationships and gifts, and giving forbidden privileges to patients.
Principles of Therapeutic Nurse–Patient Relationships
How the psychiatric/mental health unit administrator or manager explains the professional nurse–patient relationship and establishes standards for orienting new nurses, educating nurses, and responding to boundary issues is important. For example, when a new nurse moved from psychiatric/mental health to another area, she kept visiting a mental health patient as a “friend.” The manager told the nurse to stop visiting the patient because it was inappropriate as she was no longer part of the treatment team. The nurse had difficulty seeing her friendship was inappropriate and a relationship boundary violation. Professional relationship boundary violations typically reflect the gratification of nurses' needs at the expense of patients' needs. However, sometimes a boundary (e.g., no dual relationships) becomes unrealistic to apply rigidly in some settings so the context becomes important. For example, if a nurse lives in a small community and one patient has been the only mechanic available locally for years (e.g., a financial relationship), the nurse could consult with his/her supervisor and treatment team to discuss how to ensure the financial relationship does not compromise the patient's care.
Considering Boundaries in Context
Although some boundaries are straightforward in many settings (e.g., no sexual relationships with current patients), some limits may need to be considered in contextual variables (e.g., the community environment, prior relationships, common sense, setting, philosophy). Nurses must consider the issue of dual relationships in context; generally, dual relationships (e.g., not providing therapeutic treatment to a relative or hiring a patient to provide computer services) are avoided. However, in rural and small communities, nurses will have prior and future relationships with patients that are unavoidable and must be considered (Corbett & Williams, 2014). In a small town, nurses may care for a relative on the only mental health unit. Often close relationships among nurses and older adults in rural areas enhance the patient's well-being and support positive health even though it may be considered over-involvement (Corbett & Williams, 2014). In other situations, no hard and fast boundary standards exist (e.g., how much time should pass before nurses can have social or other relationships with prior patients?). For example, one colleague met a patient in restraints and seclusion who later became a professional colleague.
In some instances, such as gift giving, nurses can appreciate the intent and accept a small token gift or redirect a larger gift. When dynamics are considered, a small thank-you gift (e.g., cookies, thank-you notes) that patients or family provide for nurses seem to be a reasonable exception to the prohibition on gifts. However, patient bequests of large amounts of money to nurses are problematic. In setting limits on expensive gifts, the therapeutic goal is not to embarrass patients or blame nurses but to explain the reason and limit the behavior. Often a family or patient's cultural norms require they provide a visible “thank you” to nurses and this cultural value can be recognized, appreciated, and directed into an acceptable alternative. For example, instead of a $300 gift card, nurses can appreciate the thought, explain that the regulations prohibit accepting financial gifts, and offer an alternative (e.g., write a note to the manager about what helped recovery). Some hospital settings invite patients to write a brief award nomination or note explaining how nurses facilitated recovery. These nominations are shared and honored at regular intervals and are appreciated.
Managing Risk and Self-Care
Nurses who understand the risk factors for boundary violations can anticipate and proactively maintain therapeutic boundaries (Ashton, 2015). When patients encourage nurses to violate a boundary, nurses can examine the dynamics that prompt crossing boundaries and respond thoughtfully. Nurses can initiate a discussion and share their experience of these boundary challenges and how they have responded. Nurses who feel stressed about boundary issues can examine these issues in consultation with senior colleagues, chaplains, social workers, or employee assistance programs. Self-reflection, mindfulness-based stress reduction, and other regular stress management programs will also enhance self-care (Jones et al., 2008; Smith, 2014).
Nurses may also have access to clinical supervision groups at work, in the community, or in academic programs. Some dynamics (e.g., impulsivity, neediness, traumatic experiences) may be risk factors that prompt patients to encourage nurses to cross professional boundaries. For example, one patient with suicidal impulses kept asking staff to share their suicidal impulses.
Early trauma, such as abuse and chronic illness, may intensify boundary challenges. Trauma affects the patient directly. When the patient relates trauma to nurses, nurses may also experience the intense emotions, which is called secondary trauma stress or compassion fatigue (Von Rueden et al., 2010). For example, a patient may tell a nurse about her rape and the nurse finds him/herself dreaming about it, thinking about it, and feeling some of the traumatic experiences. Nurses also bring their own vulnerabilities, which require understanding so they do not prompt boundary violations. When nurses are tempted to violate a boundary, they must consider their own needs and dynamics as well as patients'. Asking how this violation could harm the patient or mental health milieu is important. Seeking consultation or coaching from a preceptor, supervisor, or senior colleague is wise.
Managing Professional Relationship Challenges and Self-Care
Challenges exist in professional relationships as nurses care for patients whose dynamics can often trigger their reactions. The nurse's and patient's early stressful experiences can predispose them to boundary violations. Nurses must be aware of and understand the impact of professional work and exercise self-care. Nurses must recognize their personal conflicts, issues, or countertransference (Stefana, 2015) that they bring to these relationships. Sigmund Freud coined the term countertransference to describe situations when the therapist's emotions were transferred to the patient, and this term has been expanded to include nurses in mental health environments. If nurses typically responded to neediness with anger and frustration, a countertransference reaction would occur if nurses displaced these feelings to needy patients. Nurses must monitor their emotions and understand and analyze tendencies to countertransference reactions so they can respond therapeutically.
Nurse managers can help nurses anticipate some of these issues by discussing patients and potential relationship risks that may emerge. They can also encourage open discussion regarding nurses' responses to patients. Often managers can anticipate which patients are likely to evoke nurses' reactions and alert nurses to these possibilities. Consultation, case conferences, and educational sessions can engage nurses in considerations of patients' common defense mechanisms, dynamics, or countertransference reactions and challenges that may occur. Regular interdisciplinary case conferences can allow time for nurses to share their responses to patients and offer a safe environment for discussing transference and countertransference issues. When these challenges occur, nurses can use reflection, supervision, consultation, peer support, mental health team collaboration, and meditation to explore and manage the relationship issues. Managers can often help nurses examine what leads to crossing and handling boundary violations. Because their formative educational programs may not have discussed these boundary issues, some nurses may need support to understand the dynamics and their responses that crossed relationship boundaries.
For example, a new nurse on the mental health unit felt a kinship with patients who had served in the military. One Veteran/patient discussed a distressing and troubling situation: he needed to buy a watch before the 2-day sale ended but could not get the funds from patient accounts until after the 3-day weekend. The nurse agreed to purchase the item for the patient and then be reimbursed. Exchange of money is a professional financial boundary violation and is not acceptable (ANA, 2010; National Council of State Boards of Nursing, 2014). The manager coached the nurse about managing and avoiding professional relationship challenges with patients, particularly Veterans. The manager also realized that the nurse may not have learned about the dynamics and countertransference in training. Although the manager could have invoked more serious discipline, she realized the new nurse had not recognized the countertransference reaction that led to the boundary infraction, and chose to educate the nurse and help increase awareness of the dynamics, and explained that future such infractions would receive discipline.
Role of Administrator/Nurse Manager
Nurse managers can establish regular review of standards and policies regarding professional relationships and boundaries (ANA, 2010; American Psychiatric Nurses Association [APNA], 2014). Nurse managers aim to be fair and equitable in applying these standards. The standards can be discussed and explained, and the rationale for standards explored. Such discussions offer nurses a forum for considering and asking about potential conflicts or boundary lapses. For example, nurses can share feelings and seek guidance about setting boundaries about confidentiality when a newly admitted patient is a relative. The nurse wants to assure the relative that she will not disclose his information to other family members. The manager can also consider whether to have other nurses serve as the primary nurses and clarify the rationale for this decision. Other nurses can share that a patient has asked her for a date after psychiatric unit discharge and the consultation group can assist the nurse in exploring the implications of this request and the patient's needs. When nurses receive regular supervision, this is also a good topic to discuss with a supervisor and ensure examination of the underlying dynamics.
Regular interprofessional conferences that discuss cases and ethical issues or a discussion with the manager also offer useful ways to look at the challenges to the professional relationship and examine boundary violations and underlying dynamics. Although nurses may enjoy when patients say, “You are the only one who understands me and can help me,” analyzing what patients need or are trying to accomplish with this compliment is essential. The compliment is favorable on the surface. However, it can also split nurses or create a covert alliance between the patient and nurses and be a precursor to asking for special privileges (Blass, 2015). It may also be a way of bolstering patients' self-esteem and, if so, it is necessary to explore their self-esteem and realistic ways to strengthen it.
Nurse managers can introduce new issues, such as how social media may offer opportunities for boundary lapses, and ask if nurses think they should “friend” or communicate with mental health patients on the mental health unit using social media. In this case, “friending” a patient can signal a social relationship instead of a professional nurse–patient relationship (ANA, 2010; National Council of State Boards of Nursing, 2014). With a discussion of this boundary comes a discussion of how long the boundary should be respected after patients leave mental health treatment. If nurses previously connected on social media with patients in a small town or community, the group can discuss the limits on this communication during and after hospitalization, and suggest how to tell patients about the reason for the nurse's changes in social media use. In mental health settings, nurses' communication with patients should be discussed openly in the health care team. In addition, nurses' use of social media with patients during hospitalization may disrupt this standard and set a level of secrecy that is not conducive to therapeutic treatment. Nurses should avoid social media, as the risk of breaching patient confidentially and violating HIPAA is too great (Sterling, 2015).
Serious boundary violations involve confidentiality, intimate sexual relationships, expensive gifts, excessive self-disclosure (e.g., nurses share personal suicide attempts and methods), and secrets (e.g., nurses agree not to disclose a patient's suicidal plan) (Chiarella & Adrian, 2014; Jones et al., 2008; National Council of State Boards of Nursing, 2014). Often serious violations occur after minor boundary lapses were allowed without constructive confrontation, limits, and/or discipline. In one extreme example, a new nurse flirted and was sexually provocative with the nurse manager, who misidentified this as a cultural issue and did not tell the nurse it was inappropriate and unacceptable, and that such behavior would be disciplined. Later, the nurse accosted a patient's older adult wife who was partially paralyzed. The wife was staying overnight in a family sleeping room that was not securely locked. The nurse came in to “comfort her” and offer a backrub and orange juice. The backrub became intimate. The wife sued the hospital. Setting limits promptly may reduce the risk of repeated behavior.
Nurse managers must also consider boundary lapses or violations and any knowledge deficit or interpersonal needs that facilitated the lapse. Considering if nurses knew or should have known the boundary lapse was wrong and the impact of the lapse is important in deciding the response (e.g., education, coaching, level of counseling or discipline). Ensuring that nurses know the impact of the boundary lapse and why it is unacceptable is critical.
Nurse managers have an important role in establishing an environment where nurses reflect on and consider their needs and dynamics as they care for patients in mental health. In some areas, nurse managers can call on other resources (e.g., chaplains, social workers, employee assistance programs, interprofessional conferences) to assist nurses with considering and resolving some of these issues. In other areas, nurse managers will introduce these issues in meetings, huddles, and case conferences. Whatever the setting, the goal is to facilitate an environment where norms include looking at professional nurse–patient relationship issues in a supportive, educative milieu where everyone is engaged in learning. Not all nurses have had similar educational foundations and some may not have learned about relationship boundaries and may be vulnerable. When coaching and education are conducted in a blame-free environment, everyone learns and benefits from understanding what led to a boundary violation and how to prevent repeat violations. In addition, nurse managers have the role of setting limits and guiding, coaching, and disciplining nurses who experience boundary lapses or violations.
The caring and compassionate nurse–patient relationship is the hallmark of nursing care. However, nurses struggle with challenges to their professional boundaries. In nurse–patient relationships, nurses typically have more power than patients. Challenges occur when nurses are tempted to overstep boundaries. Dual relationships occur when nurses engage in other relationships (e.g., sexual, financial) with patients in a manner that disallows the patient from making an independent decision and leaves the nurse potentially unable to promote the patient's welfare. For example, the current author had students try to become patients in her private nurse therapist practice. These requests for dual relationships were denied. Across all nursing settings, these boundaries ensure the professional nurse–patient relationship are safe, respectful, and focused on patients' needs (National Council of State Boards of Nursing, 2014). Although some boundaries are clear, others may need clarification in different settings (e.g., dual relationships in small communities). Nurses must reflect on their own behavior, anticipate conflicts, and proactively maintain boundaries (ANA, 2010). Nurses must also prevent relationships that disrupt the therapeutic milieu (e.g., friendship, actions outside scope of practice). As technology grows, nurses must consider social networking activities that may overstep boundaries. Nurses can reflect on their own dynamics, consider boundary challenges, and seek guidance from coaches, supervisors, and various professional colleagues or organizations. They can discuss boundary challenges in case conferences, supervision, or educational meetings (ANA, 2010; APNA, 2014). Nurse managers and leaders have a role in encouraging thoughtful discussion, as well as coaching and educating staff, about boundary challenges and consequences.
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Examples of Professional Boundary Violations
|Excessive attention/over-involvement (special privileges)||To seek forbidden privileges, one patient says, “The other nurses are kinder, more helpful, and more understanding and give more privileges.” The nurse relaxes the rules or gives more privileges, which is disruptive and pits one nurse against others and reduces a focus on the patient.|
|Business/financial (gifts and money)||To express gratitude, one patient gives the nurse a $300 gift card. Another nurse buys expensive presents (e.g., designer pen sets) for one patient. One patient asks the nurse to purchase an expensive watch for him (his funds are not available until Monday) and offers to reimburse the nurse.|
|Excessive self-disclosure||One patient asks about the nurse's experiences with suicide and the nurse discloses her suicide attempt. Another nurse shares personal information.|
|Intimate sexual behaviors||The nurse says the patient needs to be “loved” and starts a sexual relationship with the patient and hopes to marry him/her.|
|Dual relationships/role reversal||The nurse wants to be a “friend” to the patient and continues to visit after he/she moves to another unit. The nurse tells the patient about her marital infidelities and desire to get a divorce.|
|Social media and friending||A nurse “friends” and corresponds on social media with patients on the mental health unit. Another nurse posts photographs of a patient's post-fall injury on social media.|
|Impaired colleague||The evening nurses notice and ignore an inebriated psychiatrist who smells of alcohol as he arrives to see his patients. The supervisor sees and confronts the psychiatrist and says he cannot see patients in this condition. The psychiatrist goes home. The nurse calls the back-up psychiatric coverage.|
|Exercise power (imbalance, bullying, intimidation)||Regular smoking or activity breaks are at 8:30 a.m. daily. Some nurses give a break early as a reward for favorite patients or withhold it as punishment.|
|Keeping secrets||The patient asks the nurse to keep a secret—that he wants to kill someone and himself. The nurse agrees and then is in a quandary about whether to share the information or keep the promise to the patient.|
Principles of Therapeutic Nurse–Patient Relationships
|The Professional Nurse…|
|Demonstrates professional judgment and is responsible for setting, delineating, and maintaining boundaries.|
|Holds responsibility for setting the beginning, middle, and end of relationships to meet patients' needs.|
|Sets the same boundaries for patients and their friends and families.|
|Helps colleagues clarify boundaries.|
|Clarifies dual relationships.|
|Makes limited self-disclosures in the service of patients' needs.|
|Demonstrates honesty and integrity.|
|Behaves carefully in post-termination relationships.|
|Recognizes that variables (e.g., setting, community influences, needs of therapy, patient needs) influence boundaries.|
|Reflects on boundary crossings and their implications, and avoids repeated violations.|
|The Nurse Avoids...|
|Friendships, dating, and romantic/sexual relationships with patients.|
|Inappropriate relationships that provide personal, financial, or other benefits.|
|Receipt or exchange of costly gifts.|
|Disclosure of personal or intimate information about oneself.|