Nurse-client relationships are therapeutic, focus on client needs and are defined by professional boundaries.
Professional boundaries are the spaces between the nurse’s power and the client’s vulnerability. These boundaries create a zone of helpfulness - allowing for a safe connection between you and the client. One way to look at these boundaries is as a continuum or range of behaviors. At one end is the zone of over-involvement and at the other, under-involvement. The zone of helpfulness or therapeutic relationship is in the middle. Client harm can occur at either end of the continuum.
As the nurse, you are always responsible for establishing and maintaining appropriate boundaries, regardless of how a client behaves. Some boundaries are clear-cut. Others are less clear and require your professional judgment. It’s important that you are able to recognize when a professional relationship is slipping into the non professional realm and take immediate action.
Power, trust, respect and professional intimacy are the key components of nurse-client relationships. Regardless of the context or length of an interaction, these components are always present.
The power of the nurse comes from the professional position, the access to private information about the client and the client’s need for care. Clearly established boundaries allow the nurse to manage this power differential and meet the client’s therapeutic needs within a safe interaction.
Within the nurse-client relationship, a power imbalance exists between you and your client. The client‘s need for your professional expertise makes them vulnerable. Your influence, access to information, and ability to advocate for them can add to their vulnerability. Some clients are particularly vulnerable, such as those with:
To effectively manage this power and set appropriate boundaries, you need to:
Inadvertent boundary crossings or violations can result from attempts to minimize or equalize power. Although these crossings or violations are unintentional, they may harm the relationship and client. Using power appropriately allows you to focus on maintaining the client’s safety and dignity.
Trust is integral to a therapeutic relationship. Your clients must trust you will act in their best interest at all times. Trust can be fragile – it’s important to keep promises to your client. If trust is breached, it may be difficult or impossible to re-establish.
Respect is the recognition of the inherent dignity, worth and uniqueness of every individual, regardless of socio-economic status, personal attributes and nature of the health problem. Respect is basic in a therapeutic relationship—to knowing the client as an individual with valued priorities, needs and wants.
You must treat all clients equally and in an unbiased, non-judgmental manner—even if a client evokes strong negative emotions. Maintaining a respectful relationship requires recognizing your own personal values and biases and taking steps to minimize potential negative effects.
Professional intimacy is inherent in the type of care and services that nurses provide. This includes physical activities and psychological, spiritual and social elements of care. Access to a client’s personal information contributes to this.
Boundaries guide you in what you should say and do – as well as what you should not. They help to safeguard both you and your client by preventing actions and intention from being misunderstood.
Remember, it is always the nurse’s responsibility to maintain appropriate professional boundaries with clients and their significant others.
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 client.
Some individual behaviours may appear harmless but when put together, form a pattern indicating a boundary has been crossed.
Examples of boundary crossings:
Boundary violations can result when there is confusion between the needs of the nurse and those of the client. Inappropriate relationships may start with something benign then gradually progress until the nurse has clearly violated a boundary.
Boundary violations can cause distress for the client, which may he/she may not recognize or feel until harmful consequences occur.
Examples of boundary violations:
Professional sexual misconduct is an extreme form of boundary violation and includes any behavior that is seductive, sexually demeaning, harassing or reasonably interpreted as sexual by the patient (e.g., making a joke about breast size).
Professional sexual misconduct is an extremely serious violation of the nurse’s professional responsibility to the patient. It is a breach of trust.
Maybe you’re uncertain or wonder if you’ve crossed a boundary with your client. Perhaps someone points out how others could view your behavior. If you’re concerned a potential boundary issue -- take steps to address it right away. Reflecting on the situation, your behavior and exploring concerns can help you understand your own feelings and motives and recognize the effect of your actions on the client. Consulting with a knowledgeable and trusted colleague is an objective place to start.
As a nurse, you are responsible and accountable for your nursing actions and professional conduct. If you’ve breached a professional boundary, you must take steps to restore the boundary appropriately. It may be necessary to withdraw from or end the relationship.
Behaviour outside the zone of professional behaviour requires intervention and/or reporting. If you are unsure if reporting is required, call the Nursing Concerns Coordinator to discuss.
In situations where you have both a personal and professional relationship with a client, you are acting in a dual role. When you have a personal relationship with someone, you may find it difficult to be objective enough to also have an effective professional relationship. You may have difficulty separating personal feelings, values and beliefs from your professional and ethical obligations.
CRNBC recommends that when possible nurses avoid dual roles and transfer overall responsibility for care to another health care provider.
CRNBC thanks the National Council of State Boards of Nursing for their permission to quote and adapt, in whole or in part, from their publications on professional boundaries.