Being clear about professional boundaries: nurses must always maintain their professional boundaries and be very aware of events or situations that may threaten them. There is plenty of information to help nurses understand this critical practice issue.
Thus it is timely to do a brief literature scan of some of the general trends and debates regarding professional boundaries and where to find learning tools on this important issue.
A broad definition of professional boundaries is the "limits which protect the space between the professional's power and the client's vulnerability". (1)
Violations a significant issue
The Nursing Council here, in its forums in 2006, stated that violations of professional boundaries were a significant issue in their case reviews, including the following categories:
* sexual/intimate or inappropriate relationships;
* accepting gifts or money;
* inappropriate financial dealings with patients;
* inappropriate relationships with colleagues. 2 These cases include professional boundary issues outside the therapeutic relationship with a patient and are a reminder of the importance of trust within team relationships.
The Council noted that new graduate nurses were the focus of some cases and this emphasises the need for senior nurses to educate and alert less experienced colleagues when a boundary could potentially be crossed. (3)
Although inexperience may be a factor in boundary crossings and/or violations, North American commentators state these sometimes occur with "well-educated, ethical, law-abiding professionals during periods of stress, loss and trauma. The majority are rarely the result of deliberate exploitation. Rather, they're the consequence of the well intentioned that self deceive and rationalise crossing lines for the benefit of the ill": (1)
So what factors may contribute to such boundary crossings/violations in the case of the experienced health professional? One factor may be the lack of clinical supervision or mentorship to ensure nurses have a safe place to reflect on their practice and raise any concerns they have. It is recognised that the earlier questions are discussed, the more likely it is that such issues can be resolved effectively. (4)
Other factors are contextual issues, such as managing dual relationships in rural communities. Boundary crossings are an unavoidable part of rural practice, and planning and evaluation is required to navigate these. One North American multidisciplinary health group has called for a greater emphasis on rural health care ethics to address these challenges. (5)
It is also important to consider cultural issues. The Nursing Council states cultural safety "is about relating and responding effectively to people with diverse needs in a way that the people who use the service can define as safe." (6) Once again, this requires "navigation skills" to ensure that situations where boundaries could potentially be crossed are managed effectively.
Access to ongoing professional development is vital to stay informed of this critical practice issue. In New Zealand, case reviews are available on the websites of the Health and Disability Commissioner and the Health Practitioners Disciplinary Tribunal Two examples are HDC Case report 06HDC06218, and HPDT Decision no46/ Nur06/31P. (7,8) (See also pp32-33 of this issue.) It is useful to read these cases, with the latter relating to some of the complexities in the rural context. Such reviews also outline the standards against which nursing practice is judged. An example is the Nursing Council's Code of Conduct which lists examples of behaviour that "could be considered as a basis for a finding of professional misconduct". (9) Nurses also need to be aware of employer policies on this issue.
Internet resources are also available, eg guidelines published by the New South Wales Nurses' and Midwives' Board and the College and Association of Registered Nurses of Alberta. (10,4) These guidelines contain details on the concept of professional boundaries, as well as decision-making frameworks, sets of principles for safe practice and clinical scenarios. They are a valuable adjunct to ethical frameworks as they discuss the less "dear cut" areas, eg self-disclosure and receiving gifts. From time to time, NZNO staff also facilitate workshops on this theme.
To summarise, nurses must remember we are nurses all the time, wherever we are in the community. It is vital to seek advice early when questions or dilemmas around professional boundaries arise. It is equally important that administrative and management staff in the health care team also understand the concept of professional boundaries and their accountabilities. This raises the need for education opportunities for the whole health care team. (1) With such education in mind, I look forward to reading the outcomes of the joint Australian and New Zealand research project in the future.
By professional nursing adviser Charlotte Thompson
(1) Holder, K.V., & Schenthal, S.J. (2007) Watch your step: Nursing and professional boundaries. Nursing Management; 38: 2, 24-29.
(2) Prendergast, C. (2006) Professional Boundaries. Paper presented at the Nursing Council Forum, Wellington.
(3) Nee, C.L. (2006) Where to draw the line? Nursing 2006; 36: 3, 6.
(4) College & Association of Registered Nurses of Alberta (2005) Professional Boundaries for Registered Nurses: Guidelines for the NurseClient Relationship. www.nurses.ab.ca/ Retrieved 01/08/07.
(5) Nelson, W., Pomerantz, A., Howard, K. & Bushy, A. (2007) A proposed rural healthcare ethics agenda. Journal of Medical Ethics; 33, 136-139.
(6) Nursing Council of New Zealand (2005a) Guidelines for Cultural Safety, the Treaty of Woitongi and Maori Health in Nursing Education and Practice. Wellington: Author.
(7) Office of the Health and Disability Commissioner. (2006) Registered nurse, Ms B, A District Health Board. A report by Deputy Health and Disability Commissioner, Rae Lamb. www.hdc.org.nz/files/hdc/opinions/06hdc00218nurse.pdf. Retrieved 01/08/07.
(8) The Health Practitioners Disciplinary Tribunal (2007) Decision no. 46/Nur06/31P. www.hpdt.org.nz/portals/o/nur0631Pfindings.pdf. Retrieved 01/08/07.
(9) Nursing Council of New Zealand (2005b) Code of Conduct for Nurses. Wellington: Author.
(10) Nurses and Midwives Board. (1999) Boundaries of Professional Practice: Guidebnes for Registered Nurses, Registered Midwives, and Enrolled Nurses. www.nmb.nsw.gov.au. Retrieved 01//08/07.