Which situation may indicate a violation of professional boundaries has occurred?

Professional Nursing

Evidence of good professional character -- the individual consistently acts in the best interest of patients and the public in any practice setting, including demonstration that the person is:

• able to recognize and honor the interpersonal boundaries appropriate to any therapeutic relationship or health care setting; and
  
• able to promptly and fully self-disclose facts, circumstances, events, errors and omissions when such disclosure could enhance the health status of patients or the public or could protect patients or the public from unnecessary risk of harm.
• Professional relationships are based on trust, respect & intimacy.
• The relationship is a planned goal directed interaction between a nurse & a client for the purpose of providing care to the client & their significant others.

Professional Boundaries

TBON Rules 217.1(29); 217.11(1)(J); 217.12(6)(D)

Professional boundaries are limits that protect the space between the professional’s power & the client’s vulnerability in a therapeutic relationship.  A boundary violation occurs when a client’s therapeutic needs or basic rights are infringed.

Continuum of Professional Behavior Issues

• Professional Boundaries
• Boundary Crossings
• Boundary Violations
• Professional Sexual Misconduct

A therapeutic relationship is one that allows nurses to apply their professional knowledge, skills, abilities and experiences towards meeting the health needs of the patient. This relationship is dynamic, goal-oriented and patient- and family-centered because it is designed to meet the needs of the patient and family. Regardless of the context or length of interaction, the therapeutic nurse–patient relationship protects the patient’s dignity, autonomy and privacy and allows for the development of trust and respect. Professional boundaries are the spaces between the nurse’s power and the patient’s vulnerability.

The difference in personal information the nurse knows about the patient versus personal information the patient knows about the nurse creates an imbalance in the nurse–patient relationship. Nurses should make every effort to respect the power imbalance and ensure a patient-centered relationship.

Boundary Crossings
Boundary crossings are brief excursions across professional lines of behavior that may be inadvertent, thoughtless or even purposeful, while attempting to meet a special therapeutic need of the patient. Repeated boundary crossings should be avoided:

Examples Crossings:

• Inadvertent, thoughtless, or decisive actions that deviate from established boundaries
• Are brief
  
• There is a return to the established standard
  
• May be trivial
  
  • ex: Nurse gives a personal present for a rehabilitating client to celebrate the achievement of a goal.

Violations

• Confusion of the professional’s need with the client’s need
• Have a reversal of roles, secrecy, & self-disclosure to meet the needs of the professional
  Examples:
  • Nurse discusses feelings of attraction with pt.
  • Super Nurse,
  • Flirtations and sexual misconduct

Red Flag Behaviors

Behavioral indicators can alert nurses to potential boundary issues for which there may be reasonable explanations. However, nurses who display one or more of the following behaviors should examine their patient relationships for possible boundary crossings or violations.

Signs of inappropriate behavior can be subtle at first, but early warning signs that should raise a “red flag” can include:

• Discussing intimate or personal issues with a patient
• Engaging in behaviors that could reasonably be interpreted as flirting
• Keeping secrets with a patient or for a patient
• Believing that you are the only one who truly understands or can help the patient
• Spending more time than is necessary with a particular patient
• Speaking poorly about colleagues or your employment setting with the patient and/or family
• Showing favoritism
• Meeting a patient in settings besides those used to provide direct patient care or when you are not at work
• Patients can also demonstrate signs of over involvement by asking questions about a particular nurse or seeking personal information.

Other Misconduct:

• Falsification
• Patient abuse
• Violent behavior
• Misappropriation
• Third-party referral compensation

Implications of Professional Boundaries

Nurses need to practice in a manner consistent with professional standards.
Nurses should be knowledgeable regarding professional boundaries and work to establish and maintain those boundaries.

Nurses should examine any boundary-crossing behavior and seek assistance and counsel from their colleagues and supervisors when crossings occur.
Nurses also need to be cognizant of the boundary violations that occur when using social media to discuss patients, their family or their treatment.
Professional Boundaries Video link https://www.ncsbn.org/464.htm

Instant Feedback:

The Nurse has had a bad day and she goes in to her patient and begins complaining about her colleague and what she doesn’t know how to do. How would you characterize this interaction:

Reference

National Council of State Boards of Nursing, Inc [NCSBN] (2018) A Nurse’s Guide to Professional Boundaries https://www.ncsbn.org/ProfessionalBoundaries_Complete.pdf

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