Professional boundaries can be thought of as the spaces between the caregiver’s power and the patient’s vulnerability. Establishing and maintaining professional boundaries from the onset of a patient’s admission to service helps protect the clinical caregiver, the patient, and the organization. It is important to be aware of and understand the value of a therapeutic relationship, the difference between boundary crossings and violations, some common situations where professional boundaries can be crossed or violated, and some warning signs that a caregiver might be close to crossing or violating a boundary.
Therapeutic Relationships
A therapeutic relationship is dynamic, goal-oriented and patient-centered because it is designed to meet the needs of the patient. Therapeutic relationships are important because they protect the patient’s dignity, autonomy and privacy and allow for the development of trust and respect. Professional boundaries are guidelines for caregivers to assist in maintaining therapeutic relationships with their patients.
Boundary Crossings and Boundary Violations
A boundary crossing has been defined as a decision to deviate from an established boundary for a therapeutic purpose.1 A boundary crossing happens when the normal boundaries are crossed in some way, which may be helpful to the client. Examples include: going out of one’s way to accommodate a patient with a more convenient appointment, disclosing personal information to comfort a patient, or volunteering to do tasks outside the caregiver’s job description, such as washing dishes or doing laundry. Minor boundary crossings are generally acceptable, as they are typically performed for a patient’s well-being. However, these relatively minor deviations from a patient’s care plan can lead to more inappropriate violations, which can then lead to problems for the organization.
A boundary violation is, or has the potential of being, harmful to the patient and to the therapy plan. Boundary violations occur when therapeutic boundaries are crossed and are characterized by role reversal, secrecy, or the caregiver’s needs being met rather than the patients’.
It is important for caregivers to be aware of professional boundaries as the lines can be blurred and, if crossed, can turn a therapeutic relationship into a nontherapeutic, or possibly even harmful, relationship. The following are some of the common areas where professional boundary lines may be crossed or violated.
Common Situations
Sharing personal information
Sharing personal information with the client could result in the client seeing the caregiver as more of a friend and may result in the client taking on the worries of the caregiver in addition to their own.
- Remember that the caregiver-client relationship must be therapeutic, not social.
- Use caution when talking to a client about personal matters and do not share personal information because it makes you feel better.
Nicknames and endearments
Nicknames or endearments such as “sweetie” or “honey” may be comforting to a client but could also suggest a more personal interest than the caregiver intended. On the other hand, nicknames or endearments may be offensive to the client.
- Remember that your level of professionalism is often indicated by the way you address a client.
- Ask the client how they would like to be addressed.
- Touch
While touch can be a healing tool it may also be confusing, hurtful, or unwelcome.
- Remember to be respectful of your client and avoid any physical contact beyond direct care and treatment contact, a pat on the shoulder or a handshake.
- Understand the culture and ethnic background of the client to assure that contact is in keeping with the client’s cultural customs and to help prevent misinterpretation of actions from occurring.
Gifts, tips, and favors
Accepting/giving gifts, tips, and favors may be misconstrued by another person or family member of the client as fraud or theft.
- Know and follow your facility’s policy on gifts and remember that it is okay to tell clients you are not allowed to accept these offerings.
- To protect yourself, report unusual offers or large gifts to your supervisor.
Over-involvement and under-involvement
Caregivers may become overly-involved with clients and may find themselves spending inappropriate amounts of time with a particular client, visiting a particular client when off duty, or trading assignments with other caregivers in order to be with a particular client. Alternatively, caregivers may become under-involved with a client, which could result in disinterest or even neglect.
- Focus on the needs of the client rather than their personality.
- Treat each client with the same quality of care and attention regardless of any emotional reaction to the client.
Romantic relationships
Romantic or sexual relationships with clients are never permitted. They are inappropriate as they disrupt and destroy the therapeutic nature of the relationship. This can even be considered professional sexual misconduct, which is an extremely serious, and criminal, violation.
- Remember that while it may be normal to be attracted to a client, it is never appropriate to act on that attraction.
- Avoid telling sexually oriented jokes or stories, flirting, and displaying suggestive behaviors to your clients.
Warning Signs
It is important for all staff to be alert to someone who is, or is close to, violating boundaries and policy. If a caregiver or other staff member believes that boundary violations or policy misinterpretations have occurred or could occur, it is important to share these thoughts with a supervisor. In these instances it might be beneficial to have another staff member present during care delivery. The observing staff member can provide an additional perspective and feedback relative to the professional and therapeutic relationship. Some red flags that a caregiver might be close to crossing the line regarding their relationship with a patient include:
- Acting secretively about their activities.
- Not wanting to discuss certain aspects of a patient’s care in multi-disciplinary group meetings.
- Doing things outside of the job description.
- Relating to the patient and their family outside of work hours.
“Are my actions about my own needs or the needs of my client?”
This question can be applied to any situation in which a caregiver is uncertain whether or not their actions would cross or violate a professional boundary.
Summary
Boundary issues often arise in the long term care and personal care environment where caregivers are more likely to develop relationships with clients they care for frequently and may come to know and like. Over a period of time, they will share experiences and may develop emotional connections. Caregivers must maintain their understanding that all care and service interactions be in the best interest of the client.
The true test of compliance with professional boundaries is practicing within professional practice standards and in keeping with the healthcare provider’s Code of Ethics. Staff must continually ask themselves, “Will the action taken benefit the patient and also meet the goals of the care and treatment plan?”
References
Hanna, A.F., & Dunphy Suplee, P. (2013). Don’t cross the line: Respecting professional boundaries. Nursing Management, 44(1), 32-33. doi: 10.1097/01.NUMA.0000426016.64123.51
National Council of State Boards of Nursing (2014). A Nurse’s Guide to Professional Boundaries. [Brochure]. NCSBN.org Retrieved from: https://www.ncsbn.org/ProfessionalBoundaries_Complete.pdf
