Expires September 30, The nurse-patient relationship can provide the "context for care" linked to improved patient outcomes, including satisfaction and trust. In most cases, professional standards of care and personal morals prevent inappropriate relationships from developing.
But in some cases, the nurse-patient relationship develops into a personal relationship that can lead to inappropriate behavior, including sexual misconduct. This article focuses on professional boundaries in nurse-patient relationships, describes behaviors that may be considered inappropriate, and examines possible legal ramifications of these behaviors.
According to Baca, professional boundaries support key elements of the nurse practitioner-patient relationship: Unfortunately, setting boundaries isn't straightforward.
The Code of Ethics for Nurses states, "When acting within one's role as a professional, the nurse recognizes and maintains boundaries that establish appropriate limits to relationships. Boundaries may be blurred when either party initiates conversation or physical contact outside of professional boundaries.
An example of an inappropriate conversation would be the nurse asking the patient where he or she normally hangs out on the weekends. Depending on the nurse's and patient's gender, culture, age, and ethnicity, certain behaviors may be perceived differently than intended; for example, as having a meaning that's more personal than professional. Nurses must thoroughly understand what constitutes inappropriate behavior in healthcare environments. According to Peternelj-Taylor and Yonge, behaviors considered inappropriate can be separated into three categories: Nurses should visit their state board of nursing's website to explore how the concepts of boundaries and sexual misconduct are defined in their own state.
Besides reviewing the Code of Ethics for Nurses and the Nursing Scope and Standards of Practice, students at all levels of their nursing education should have open dialogues about what they, colleagues, and society consider to be unethical social behavior in the clinical setting.
In addition, students should be educated about the legal ramifications of boundary crossings, boundary violations, and sexual misconduct. Caution The NCSBN defines a boundary crossing as a decision to deviate from an established boundary for a therapeutic purpose. Home health nurses may help patients with tasks outside their job description, such as washing dishes or doing laundry.
A hospital-employed nurse may visit a former patient after discharge to check on his or her progress. Pediatric nurses who become attached to a patient may believe they know best and step in to make decisions rather than letting the parent make them. An example is when a child is ready to be discharged and the nurse doesn't believe the parents-who've always cared for the child's needs-are appropriate caregivers and refuses to discharge the patient.
This raises the issue of false imprisonment. Or, if the same nurse calls to check up on the patient after the hospitalization is over, this raises the question of when the nurse-patient relationship ends. Boundary crossings that seem harmless to both parties can be interpreted as the nurse showing kindness or caring or in some cases as the nurse having control over the patient.
Some may perceive these behaviors as boundary crossing; others may not. Minor boundary crossings are generally acceptable when performed for a patient's well-being, such as asking an older patient about his or her home environment before discharge. But seemingly trivial boundary crossings sometimes lead to more troublesome unprofessional behaviors. Using touch as a therapeutic agent is another gray area. See When is touch appropriate?
A female nurse enters a male patient's room just after the healthcare provider has informed him that he has lung cancer.
Noticing that the patient is very upset, the nurse sits on his bed and holds his hand, saying, "You seem upset. Would you like to talk about it? He stops crying after a few minutes, saying, "I just didn't expect that. Can the nurse's behavior be considered inappropriate? Or was she just being compassionate?
A nurse giving a patient a quick hug that's not seductive can be interpreted as a sign of compassion. Although it may be customary in American culture to hug a person to show support, this practice may not be viewed positively in all cultures. Also, because sitting on a patient's bed may be perceived as invading the patient's personal space, nurses are discouraged from doing so. Danger Sometimes nurses cross professional boundaries for reasons that aren't even arguably therapeutic to the patient.
This is considered a boundary violation. This unprofessional behavior can escalate to even more serious misconduct. An example mentioned previously, keeping a patient in the hospital when a qualified caregiver is available, could fall under this category. Taking a stricter view, Peternelj-Taylor and Yonge suggest that boundary violations are clearly harmful or exploitive "transgressions.
Forbidden One of the most serious failures of the nurse's responsibility for the welfare of the patient is sexual misconduct. 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; any verbal behavior that's seductive or sexually demeaning to a patient; or engaging in sexual exploitation of a patient or former patient. But not all examples of sexual misconduct are clear-cut.
Consider the following situation: A male nurse has been caring for a female patient who's being discharged. After completing his assessment and discharge instructions, he asks, "Do you have any other questions? Or, because the patient is being discharged, is it now considered acceptable to form a personal relationship? As professionals, nurses have the duty to set and follow their own boundaries. The patient's consent to participate in a romantic or sexual relationship doesn't lessen the healthcare professional's responsibility to maintain boundaries.
Defining when the nurse-patient relationship has ended and when the potential intimate relationship between the nurse and former patient begins is difficult. Nurses need to seek out their own state board of nursing for guidelines and timelines for when they can initiate a relationship with a former patient. These may depend on the reason the patient was being treated as well as the environment in which the care took place. Identifying those at risk According to Holder and Schenthal, few cases of sexual misconduct are reported to professional nursing boards, but more men are reported than women; their article focuses on nurses and physicians.
Any healthcare employee can cross professional boundaries, but some authors suggest that certain personalities are at particular risk.
Inexperienced or younger nurses may be at risk for committing boundary violations because of lack of experience or understanding. Some who violate boundaries may also have preexisting or underlying personal issues, such as substance abuse. Significant and emotional life events can pose risks for patients as they become vulnerable to compassionate feedback and seek to connect with others who can empathize with them.
See Which patients are most vulnerable? On the other hand, nurses too can be the recipients of inappropriate behavior by patients and may become susceptible because of emotional or significant life events.
In some nursing specialties, the practice environment may be more conducive to the development of inappropriate professional behavior. Boundary issues often arise in long-term-care and rehabilitation specialties, where nurses develop relationships with patients they care for frequently and come to know well. Over time, nurses and patients share healing experiences, bonding experiences among families, and emotional connections brought about by continuous caring relationships.
McGilton and Boscart noted in their study of patients in long-term-care facilities that patients, caregivers, and families all defined close care-provider relationships differently.