As health professionals we all work under a set of ethical guidelines laid down for us through our professional body, such as the Nursing and Midwifery Board of Australia, and through the unstated expectations of the public. While boundaries are in place to protect both health professionals and patients, they are not always as clear-cut as they may first seem.
No nurse begins her career thinking that she is going to cross or violate professional boundaries, and yet this is what happens, through a sense of familiarity and trust that has been built up with a patient, the seductiveness of the helping role, or simply a general lack of understanding of relevant boundaries. Let’s take a closer look at boundaries, followed by a few examples of how professional boundaries can be violated.
Boundary Crossings and Boundary Violations
Just as a garden fence defines the boundary of a person’s backyard, boundaries define the parameters of a professional relationship, creating a safe relational space. They “define the helping pathway – for both clients and professionals – and as such are integral to professional effectiveness” (Everett & Gallop 2000).
Literature indicates that professional boundaries can be either crossed or violated. A boundary crossing is seen as a deviation from classical therapeutic activity that is harmless, non-exploitive and possibly supportive of the therapy itself (Lederberg & Lazenby 2015). In contrast, a boundary violation “is harmful (or potentially harmful) to the patient and therapy alike because it constitutes exploitation of the patient, using the therapist-patient relationship as its vehicle” (Jungers & Gregoire 2012), for example, conducting a sexual relationship with a patient, or stealing their belongings.
Although boundary crossings may be viewed as trivial, they have the potential to progress to a boundary violation if there is an increase in the frequency and severity of the crossings.
Do you think you have ever crossed or violated a professional boundary?
Case Study 1
Sandra is a clinical needs assessor, visiting clients in their homes to assess what home help they might need. She generally visits clients a few times, and always phones beforehand to confirm her appointment.
Sandra has already visited Mrs A, an elderly widow, two times and found her to be friendly, although lacking in familial support. Upon phoning to confirm her visit, Mrs A asks Sandra to pick her up some milk so they can have a cup of tea together, promising that she has the money to repay her upon her arrival. Sandra is happy to comply with this simple request.
Has Sandra crossed a professional boundary in buying milk for Mrs A?
Some time passes and Sandra finds that Mrs A has started to ring her frequently, sometimes to discuss her nursing needs, and sometimes to ask her to run to the supermarket to pick her up a few essentials, as “she has no family to help her and Sandra means so much to her”.
- If Sandra complies, will this be a boundary crossing or violation?
- How could Sandra have refused the initial request, while maintaining a friendly, professional relationship?
- Should Sandra tell her supervisor about this relationship?
Case Study 2
Mark is a mental health nurse who loves reading. One of his patients, Mr B, is also an avid reader, and they often discuss authors they enjoy and books they are reading. Mr B offers to lend Mark a couple of books and Mark eagerly takes him up on the offer.
Has Mark crossed a professional boundary?
Upon returning the books, Mark is offered to visit Mr B’s house to see his collection and borrow whatever he would like. He is also invited to attend Mr B’s book club.
- Is visiting Mr B’s house a boundary crossing or violation?
- Is joining the same book club a boundary crossing or violation?
Case Study 3
Ella works in a busy outpatient department that treats patients on a daily basis. Mr C has been coming daily for 3 weeks and they have formed a fast friendship. When Mr C finishes treatment he gives the whole team a box of chocolates but also brings Ella a necklace.
- Is it a boundary crossing or violation for Ella to accept the necklace?
- Is it a boundary crossing or violation for the team to accept the chocolates?
Mr C then starts to visit the department frequently, ostensibly to see his treatment team, but he always asks about, or tries to see Ella.
Is it a boundary crossing or violation for Ella to continue the friendship?
Mr C invites Ella out for a coffee, “simply to say thank you for helping me during my treatment.”
- Is it a boundary crossing or violation for Ella to go?
- Should Ella tell anyone about this request?
As can be seen, often boundary violations are a process, rather than simply crossing a well defined line. Health professionals may act in a well-intended manner, yet end up crossing or even violating a boundary. As a nurse, it is important to use discretionary judgement in all circumstances, instead of merely trying to follow instructions.
If you would like to further review professional boundaries, the Nursing and Midwifery Board of Australia have all of the relevant codes and guidelines online.
- Everett, B & Gallop, R 2000, ‘Personal and Professional Self-Care’, in The Link Between Childhood Trauma and Mental Illness: Effective Interventions for Mental Health Professionals, SAGE Publications
- Jungers, C & Gregoire, J 2012, ‘Voyaging Through Best Practices in Counseling Ethics’, in Counseling Ethics: Philosophical and Professional Foundations, Springer Publishing Company
- Lederberg, MS & Lazenby, M 2015, ‘Negotiating the Interface of Psycho-Oncology and Ethics’, in JC Holland, WS Breitbart, PB Jacobsen, PN Butow, MJ Loscalzo & R McCorkle (eds), Psycho-Oncology, Oxford University Press