Provision 2 of the American Nurses Association Code of Ethics states that “The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.” A nurse must always be guided by that primary commitment to the patient. Certain situations may offer particular challenges to nurses, including conflicts of interest, collaborative situations, and issues of professional boundaries (ANA, 2015).

Conflicts of interest may present themselves in direct care settings, in working with a patient within a family context, and even in administrative settings. They may present themselves as conflicts between a patient’s values and those of the nurse (ANA, 2015).

In today’s complex healthcare system, collaboration among many parties is often critical. Nurses can help ensure participation and “facilitate informed decision-making by assisting patients to secure the information that they need to make choices consistent with their own values” (ANA, 2015).

Professional boundaries are essential because of the personal nature of nursing relationships and the need to keep the patient’s needs primary. Boundaries may be tested by anything from whether or not to accept a gift from a patient, which may be acceptable in certain situations, to dating and sexually intimate relationships with patients [which] are always prohibited” (ANA, 2015).

As practitioners in one of the most widely respected and trusted professions, nurses must be knowledgeable regarding professional boundaries and vigilant in their observation of those boundaries (NCSBN, 2015).

The Continuum of Professional Behavior

Professional boundaries may be viewed in light of a continuum of professional behavior model that views the therapeutic relationship between nurse and patient as the ideal in the center and under-involvement and over involvement as the usually undesirable positions to either side.

Over-involvement includes boundary crossings, boundary violations, and professional sexual misconduct. Under involvement can include distancing, disinterest, and neglect, and be damaging to both the patient and the nurse (NCSBN, 2014). The continuum model represents a situation in which definite lines do not exist between over- or under-involvement and a therapeutic relationship; it is usually a gradual transition (NCSBN, 2014).

The National Council of State Boards of Nursing (NCSBN) defines professional boundaries as “the spaces between the nurse’s power and the client’s vulnerability” (NCSBN, 2014). Maintaining professional boundaries is critical to open and professional communication and it supports trust, compassion, mutual respect, and empathy, which are key elements of the nurse-patient relationship (Hanna & Suplee, 2012). A nurse’s responsibility to keep the patient’s needs at the forefront and to always treat them with dignity and respect preclude many of the behaviors that constitutes crossings or violations of boundaries. Sometimes, however, it is not clear cut and details of context can be important. It is always advisable to consult a trusted colleague or supervisor when questions arise.

Boundary Crossings and Boundary Violations

[This section from Hanna & Suplee, 2012.]

Boundary crossings are generally defined as deliberate decisions to cross an otherwise established boundary for a therapeutic reason. These could include going out of one’s way to give a patient a more convenient appointment time or a home health nurse performing some non-healthcare-related task such as washing dishes or doing laundry. Accepting gifts, exchanges of personal information in order to reassure someone, or calling to check on someone who has been discharged would also fall into this category. Touch is another problematic issue in relation to boundaries. All of these have the potential to be unclear and to be interpreted differently according to personal and cultural factors.

Boundary violations, on the other hand, should send out danger signals and are usually more clear-cut because they are not being done for any reason that could be justified as “therapeutic” for the patient. These might include refusing to discharge a patient when a qualified caregiver is available, or releasing patient information in violation of HIPAA privacy regulations.

Sexual misconduct is the most extreme form of boundary violation and is always forbidden. The NCSBN defines sexual misconduct as “engaging in contact with a patient that’s sexual or may reasonably be interpreted by the patient as sexual, and verbal behavior that’s seductive or sexually demeaning, or engaging in sexual exploitation of a patient or former patient.” Other activities such as kissing or discussing possible dating activity would also fall under the sexual misconduct label.

Even these activities can fall into gray areas at times, especially when a nurse-patient relationship has technically ended. However, nurses have a professional responsibility to know and understand their own boundaries as well as rules and laws applicable in their institution and state. Never be afraid to consult a trusted colleague, a supervisor, or your state board for guidance if in doubt.

Vulnerable Populations

Patients who are most at risk for boundary violations tend to have these characteristics:

• Female gender
• A diagnosis of bipolar disorder and/or other personality disorders
• Complain of emptiness or boredom
• Are articulate and have reasonable social skills
• A history of childhood or physical abuse
• Like to keep secrets with staff
• May wish to be touched, hugged, and reassured that they’re liked

Certain practice situations such as long-term care and rehabilitation care settings may provide greater opportunities for inappropriate boundary crossings or violations.

Boundary crossing behavior can be initiated by nurses, patients, or family members, and nurses must be alert to warning signs for themselves and for colleagues. It can be difficult to confront or report a colleague, but most institutions and states have requirements and procedures for doing so. Blatant sexual misconduct that is witnessed must always be reported to supervisors, the state board, and possibly local law enforcement.