Nursing inherently involves some of the most intimate health care that people experience, during times when they are at their most vulnerable. Working in partnership with health consumers requires knowledge, skill and good judgement, especially in challenging situations where nurses find themselves in close or ongoing relationships with clients.
In New Zealand, because of our relatively small population, or perhaps because of the number of rural practice settings, sometimes nurses already know people with whom they come into contact professionally. The way that nurses understand and deal with their responses to clients – and recognise the effects of complex, challenging, or culturally different relationships – is the key to successfully managing these relationships.
Nurses learn about boundaries, and the professional values that underpin managing therapeutic relationships, during their pre-registration training. However, values and expectations around what being professional means change over time and in response to societal needs.
The Nursing Council’s Code of conduct for nurses (2012) emphasises the need to justify the trust that health consumers place in nurses as knowledgeable, capable and independent-thinking practitioners who act with integrity. Guidelines: Professional boundaries, also released by the Nursing Council in 2012, provides advice about how to work through the complex and challenging issues that are part of nurses’ everyday practice1.
Having the opportunity for ongoing professional education on boundaries, particularly being able to talk through ideas about what professionalism actually looks like in practice, is essential for nurses working in complex and rapidly changing work environments. It is also important for nurses from differing cultural and practice backgrounds to share their values about professional relationships in practice. The following discussion presents some ideas about how to frame our thinking and reasoning about professional boundaries.
Case study: Kate’s story
Kate is a practice nurse and a keen netball player in her rural town’s local team.
Some people in the rural community she practices in have to travel a considerable distance to get to town. Since graduating as a registered nurse three years ago, Kate is often approached by other netball team members for advice about health conditions. After the game on Saturdays she occasionally invites teammates and their children back to the practice where she works, as it is closed on weekends. In these informal free clinics, Kate does basic health screening, checks children’s ears and gives dietary and contraceptive advice.
Boundaries as lines or limits
Would another careful, thoughtful nurse think Kate’s actions were reasonable?
Thinking about boundaries as lines that set limits on professional activities nurses undertake with health consumers is helpful in defining how nurses ought to act.
A 2001 article by a staff member of America’s equivalent of the Nursing Council suggests that blurring lines between formal and informal roles in professional relationships can cause role ambiguity, threatening the safety of both the health consumer and the nurse. Understanding lines as limits defines behaviour that is clearly ‘out of bounds’, or a boundary transgression. While well intentioned, Kate’s actions commit two key transgressions:
- Firstly, Kate has no authority or professional mandate to undertake this ‘informal’ practice. Given that some of the women she sees are not enrolled at the health centre, she is not able to document care, or appropriately follow up or refer clients to other practitioners. She is practising outside the usual professional context without formal contractual systems and support, including the collaborative team relationships that are the hallmark of good practice.
- Secondly, using the health centre premises and equipment after hours without the knowledge or consent of the practice manager involves a degree of deception, which is both an employment and professional issue.
Boundaries and therapeutic benefit
Is there any therapeutic benefit in Kate’s actions? Thinking about boundaries as therapeutic outcomes or fitting within the ‘zone of helpfulness’ is another way of evaluating whether the nurse’s actions fit within the professional mandate for practice and the continuum of behaviour expected from health professionals. Given that Kate has no clear professional mandate for practice, these women may not fully understand the limits of her practice in consenting to a therapeutic relationship for themselves or their children.
As a graduate with three years’ clinical experience, Kate may not have the necessary knowledge, skill or resources to adequately assess health consumers’ need for care. Since she is not documenting or communicating her findings to other health professionals, Kate may be adversely affecting therapeutic outcomes for these women by coming between them and their usual health providers. In most circumstances it is appropriate for nurses to intervene in an emergency situation where they can clearly make a difference to therapeutic outcomes.
However, when members of a community seek advice from nurses outside of formal practice contexts, the best approach may be to encourage the person to see their usual health practitioner. That does not mean to say that nurses cannot discuss health concerns with people in an informal context, but it does require careful thought about the best therapeutic benefit in responding to them.
Boundaries and negotiated identities
The key question Kate needs to ask herself is, ‘Who am I in this encounter – nurse or teammate – and what is my purpose?’ Living and working in rural or other small communities where people have multiple relationships with one another presents particular challenges for health professionals.
Thinking about boundaries as ongoing negotiations in relationships is another approach.
Canadian sociologist Muriel Mellow describes this negotiation as ‘doing a dance’ by shifting or shuffling to the fore or background an individual’s personal and professional identities. This negotiation of identities and their inherent roles and responsibilities depends on the context of the relationship, and the shifts between personal and professional roles need to be discussed with health consumers “in an open and transparent way”. Consumers should also be given the choice of another health professional where possible.
Kate’s actions led to ambiguity about her role and the transgression of professional boundaries as she did not define the purpose of her role, i.e. nurse or teammate, in her differing relationships with members of her community. She elicited privileged information from teammates and undertook physical assessments without a clear, professional mandate.
A nurse’s responsibility for confidentiality and the need to balance professional power with the health consumer’s vulnerability also become confused when a nurse’s professional identity is brought to the fore within an informal or personal relationship.
Discussion: the risk of stepping over the line in the desire to help others
Kate’s concern with the wellbeing of people and her desire to contribute voluntary services to her community show how ‘informal’ practice may put both health consumers and nurses at risk. Professional boundaries define who we are, how far we can go, and what we should do within therapeutic relationships.
In professional relationships, limits are primarily concerned with managing the power of the nurse, and the client’s vulnerability, needs and interests.
Boundaries help to guide nurses if they are moving closer to risky territory, but the dilemma is sometimes in knowing how close is too close, and how far is too far.
Weighing up the therapeutic benefit of closeness and distance is a matter of judgement based on the context of client care, the expectations of the profession, and the recognition of what another thoughtful, careful nurse might do in a similar situation.
Crossing a boundary can be understood as going beyond the usual limits required for helpful therapeutic relationships. Nurses possess a particular kind of social generosity that sometimes finds expression beyond our work roles, but the very qualities that make us good nurses can sometimes contain the seeds of our undoing. Having said that, there are times when a carefully considered boundary crossing, such as an appropriate disclosure of a personal experience, may have therapeutic benefits.
The difference between a boundary crossing and a boundary transgression is the degree of harm done to the client, family or whānau; for instance, where a nurse meets personal needs in ways that exploit the vulnerability of others. A central element of boundary transgressions is the degree of complexity that develops in the relationship, and also the nurse losing sight of the therapeutic aim and professional purpose of their interactions with the client. :
1. Nursing Council of New Zealand (2012a). Guidelines: Professional Boundaries, Wellington, NZ
2. Nursing Council of New Zealand (2012b). Code of Conduct for Nurses, Wellington, NZ.
3. Sheets V (2001). Professional boundaries: Staying in the lines. Dimensions of Critical Care Nursing 20(5), 36-40.
4. Mellow M (2005). The work of rural professionals: Doing the gemeinschaft‐gesellschaft gavotte. Rural Sociology 70(1), 50-69.
5. Frank A (2002). The painter and the cameraman: Boundaries to clinical relationships. Theoretical Medicine 23, 219-232.
Professional boundaries in practice
Professional boundaries define the scope of therapeutic relationships. Boundaries are limits or borders to relationships that are both enabling and constraining, providing a clear focus for the therapeutic aim and purpose of healthcare encounters.
Defining the limits protects both the nurse and health consumers, ensuring that whatever activities are undertaken within the therapeutic relationships benefit health consumers. Professional boundaries also refer to the differences between scopes of practice, with the authority and professional mandate to undertake some therapeutic actions limited to specific scope of practices.