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Nurses provide emotional, physical, and psychological care to patients every day. However, these interactions put them at risk for crossing the lines of professional boundaries in nursing.
This is especially true in healthcare settings like home health and hospice when care is being provided in the patient’s home.
For instance, as a hospice nurse, you spend a significant amount of time with your patients and their families. Once in their home, you get acquainted with their family, pets, and friends.
Also, it’s not uncommon to hear patients refer to their hospice nurses as “family.”
It’s these types of relationships that can blur the lines of professionalism and cause boundary violations.
What Are Professional Boundaries?
First, the National Council of State Boards of Nursing (NCSBN) defines professional boundaries as “the spaces between the nurse’s power and the client’s vulnerability.”
Now, let’s break that down in a little bit more.
To begin, as a nurse, you are in a position of power and authority when you provide care.
For instance, you may need to touch, feed, or even bathe a patient. You may also need to console the patient or family during times of distress.
As a result, you are in a position of trust and authority.
Furthermore, the community impression of nurses can influence this dynamic as well.
For one thing, nurses have been consistently voted the most honest profession for the past 19 years.
According to a 2020 Gallup poll, nurses ranked 89% for honesty.
That’s right as a nurse, you are ranked higher than physicians, teachers, and even clergy.
Crossing Professional Boundaries
As a hospice nurse, one of the things you may enjoy is spending quality time with your patients. For instance, you might get to sit at the kitchen table and reflect with your patient while they have their morning coffee.
Or perhaps you get to know their dogs and cats, and share wonderful stories about day-to-day happenings.
Additionally, you experience the good days and the bad days. It’s these intimate moments that make you fall in love with hospice nursing.
However, when you form close bonds with your patients over time, you are at risk for professional boundary-crossing.
When those under your care are fragile both physically and emotionally, it’s critical to maintain professionalism.
One example that comes to my mind is also one of the mistakes that hospice nurses frequently make. As a nurse, it might be tempting to promise the family that you will be present when their loved one dies.
However, the problem is, this creates the perception that you are the only one who can care for the patient.
As a nurse, you should ask yourself if your actions are for the patient or for your own personal gain.
Examples of Crossing Professional Boundaries
- Spending time outside of work with your patient and/or family
- Favoring one patient over another
- Trading assignments to care for a particular patient
- Frequently thinking about your patient even when you’re off work
- Sharing personal information with the patient
- Frequently thinking about the patient when your shift ends
- Defensive behavior regarding your relationship with the patient
Ways to Maintain Professional Boundaries
1. Avoid Personal Relationships
First, it can be difficult to say no to your patient. If they ask you to attend a special event or family gathering, you might be inclined to say yes.
However, you should remember that you are caring for them in a professional capacity.
It is ok to politely decline the invitation. (And you should!)
2. Don’t Get Involved in Business Relationships
Again, you are a healthcare professional so don’t blur the lines.
For instance, if you sell a product on the side, it might be tempting to share this with the patient and family. (DON’T!)
This is especially true if you have knowledge of particular interests they may have. Selling to the patient could be seen as taking advantage of them and crossing professional boundaries.
Again, you have access to personal and private information and it’s your duty to protect it, even from yourself!
3. Familiarize Yourself With “At Risk” Patients
This includes:
- elderly patients (home and long-term care)
- pediatric patients
- patients with mental health disorders
- lonely patients and/or their family members
- physically abused patients
Warning Signs of Professional Boundary Crossing
The warning signs may not be obvious at first and they may be subtle.
- Talking about your personal issues with the patient/family
- Flirting and inappropriate touching
- Spending more time than is necessary with the patient
- Speaking negatively about your employer or co-workers
- Showing favortism
- Posting about patient on social media (more on this later)
- Meeting patient outside of work setting
- Role reversal- when patients feel the need to provide support to the nurse i.e emotional or financial
Has this ever happened to you?
You’re chatting it up with your patient and before you know it, they ask if you have any kids. (small talk)
The next think you know, you’re sharing pictures and stories about your family. Now at each visit, the focus is on you and what’s going on with your family.
That doesn’t seem so bad, right? Well, that is until you find yourself sharing information about your kids health and complaining about your hours and how you don’t get to see them as much as you’d like because you have to work on call.
Now, the patient is concerned about your needs and doesn’t want to call you when they are in pain.
Their reason for not calling: They didn’t want to call you away from your family.
I’ve seen this happen more times than I’m comfortable admitting.
When the patient knows too much about you, this can lead to boundary crossing.
So what can you do?
Try saying this next time: “I could talk about my kids all day, tell me more about your family.”
EXPERT TIP: If you have a talker, try to coordinate your visit with the home hospice aide or the social worker so that you can focus on direct patient care. You can also involve the spiritual care team.
How the IDG Can Help?
If you are aware of special dates for the family or a need, you can involve the volunteer coordinator.
For instance, volunteers can drop off special gifts or coordinate special days for your patient.
Some things I’ve seen in the past is volunteers deliver flowers on valentines day or adopt a family for Christmas. They can have also mowed the grass.
You shouldn’t show up on your day off to fix a leaky sink or mow the grass. I don’t care how handy you are, this is not your job and could be considered boundary crossing.
By involving the IDG, you ensure everyone on the team is involved.
This also minimizes the risk of crossing boundaries.
Consequences of Crossing the Line
This is serious business folks so listen up.
If you think you might be entering an inappropriate relationship, STOP right away.
First and foremore, examine your own behaviors and pull it together.
Many state boards have guidelines and standards of practice that specifically address inappropriate conduct in the workplace.
The consequences of crossing professional boundaries can include criminal and civil penalities so this should be taken very seriously.
Possible disciplinary actions can include:
- Verbal discipline
- Written discipline
- Termination of employment
- Being reported to your state board of nursing
- Criminal and/or Civil charges
- License suspension/revocation
Social Media
Honestly, there’s no way to write about professional boundaries in nursing without talking about social media.
Now more than ever, nurses are sharing stories, images, and memes about patient care and scenarios that are perfectly on point.
While this is a great outlet, it should still be treated with some integrity.
Even if you inadvertently cross the line, the consequences can still be severe.
Boundaries in Rural & Small Communities
I’ll start by saying this one is tough. As someone who grew up in a small town, I know first hand that maintaining privacy can be tricky at times.
For example, if someone in our town died, everyone knew because the black hearse was a sure giveaway. Inevitably, the phone would ring and the speculation would start.
It can be the same way in hospice.
Consider this, does your car have your companies logo all over it? Does your agency have a specific color of uniform that is recognized in the community.
If so, then this a red flag to neighbors that someone in the residence is sick and receiving hospice care.
Simply stated, when you work in the patient’s home, you’re at risk.
If you’re a nurse in a rural community, you should set professional boundaries.
Do you need to be removed from the patient’s care?
Personally, I think this is a judgement call. Is it difficult to separate your personal and professional relationship?
If so, then you might want to allow someone else to provide care so that you can continue to support the patient as a friend.
Conclusion
Finally, understanding where the lines cross can be a little gray.
It’s important to remain aware of situations that blur the lines and address them right away.
Again, the difference is what are you doing for your own personal gain versus what is best for the patient.
Generally, ask yourself these questions: Would I do this for every patient every time? Is this for me or the patient?
If you want to stay within the professional boundaries in nursing, you should:
- Treat all of your patients with dignity
- Maintain privacy and confidentiality
- Only share what is necessary (don’t gossip)
- Put your patient’s needs before your own when providing care
- Establish written policies and procedures that address professional boundaries.