Sunday, November 27, 2011

Professional Boundaries in Nursing


"Boundaries are mutually understood, unspoken physical and emotional limits of the relationship between the patient and the nurse." (Farber, 1997)
When these limits are altered, what is allowed in the relationship becomes ambiguous and possibly unethical. The health and well being of patients depends upon a collaborative effort between the nurse and the patient. Patients are extremely vulnerable to boundary violations because they trust us as their health care providers. They come to us in a time of need, presenting with physical, and often emotional, distress. Some patients demand continuous attention but are unaware of their insatiable neediness. (Muskin and Epstein, 2009)

Warning signs of unhealthy boundaries could be:

1. You share personal problems or aspects of your intimate life with patients.

2. You keep secrets with patients.

3. You become defensive when someone questions your interaction with

4. You have received gifts from a patient.

5. You speak to the patient about your own professional needs or inability.

6. You speak poorly of co-workers or the hospital to patients.

7. You talk to patients/families about things that are out of your scope of practice.

8. You give certain patients extra time or attention.

9. You give patients personal contact information or money.

10. You fail to set limits with a patient.

11. You spend duty time with patients.

12. You feel that you understand the patient’s problems better than other members of the healthcare team.

Violations of professional boundaries are almost always to make ourselves come across to the patient as the victim. It does not matter whether you are whining to a patient about your personal life or accepting a gift, you have altered the role of caregiver to the person in need of care.

When you speak ill of coworkers or the hospital, you are looking for sympathy from the patient to feel sorry for your situation, whatever that may be. If you speak to a patient about the poor staffing or your inability to perform a task, you instill fear in the patient in order to achieve power. You are using their situation for personal gain.
All nurses are vulnerable to boundary problems. Nurses who have patients with extended length of stay or treatment are especially vulnerable.
To be more aware of boundary issues you may be unaware of, begin to listen to what you say to patients. Is your tone, approach and conversation professional? Is there a clear distinction that this is your patient and you are the professional nurse? Are you telling the patient or family specific information for personal gain?
If you see other nurses violating professional boundaries, you do not help the patient or the nurse by not bringing the issue to someone's attention. Take the time to mentor less experienced nurses with what they could have said, or other choices. If the violation is repeated, you need to inform the nurse’s supervisor.
Boundary violations occur one small step at a time and almost always without warning, yet if we are aware, the warning signs are there. What appears to be innocent may end up being a commitment to an unprofessional relationship with a patient.
The best thing you can do is to remain mentally healthy. Take time to take care of yourself and your family. If you are feeling vulnerable with a specific situation or patient, do not be afraid to ask a peer to help you by taking that patient assignment.
Farber, N, Novak, D, O’Brien, M. Love, Boundaries, and the Physician-Patient Relationship Arch Int Med 1997;157: 2291-2294.
Muskin, P,Epstein, L. Clinical guide to Countertransference. Current Psychiatry 2009; 8:25-32
About the Author: Kim Holland has 20 years experience in the field of Psychiatric Mental-Health Nursing and received AACN Certification as a Board Certified Advanced Practice Psychiatric Nurse in 2004. Kim brings years of leadership experience, ranging from child mental health to geropsychiatry. Kim has also taught psychiatric nursing as an adjunct professor at Oklahoma University School of Nursing and is dedicated to enhancing the psychiatric skills of nursing students.
Click here for more on Kim Holland.

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