Nursing Professional Boundaries: Concepts, Roles, and Ethics

Introduction to Professional Boundaries in Nursing

There are boundary issues in every aspect of nursing practice. Some of these issues range from stopping to purchase groceries for a home-bound client and accepting gifts from clients, to forming friendships with clients and engaging in sexual relationships with them. While there is substantially more gray area than black and white in the study of professional boundaries, nurses can make appropriate decisions if they have the relevant information concerning the fundamentals of professional boundaries (Kagle and Giebelhausen, 1994). Therefore, it is advisable for nurses to read additional information and participate in discussions with their colleagues to broaden their comprehension of the topic.

Professional boundaries refer to the limits that protect the space between the professional's authority and their client's vulnerability. Upholding proper boundaries helps to control that authority, allowing for safe connections between the nurse and client based on the client's needs. Owing to the various bodies of research on the topic, different definitions of boundaries and professional boundaries have emerged. According to Avis et al. (1983), the term "boundary" refers to the concept of limits, lines, or margins. According to the outline of nursing practice, nurses meet the professional requirements for practice when they exhibit the knowledge, proficiency, and attitudes apparent in practice standards and capabilities.

Many studies have concentrated on therapeutic behavior and have arrived at their own definition: professional boundaries refer to lines that separate the therapeutic behavior of nurses from any behavior that could significantly reduce the benefits of nursing care to patients, clients, and society (Justice, 1995). Although it is sometimes possible to identify professional boundaries clearly, prior literature and various surveys suggest that professional boundaries are complicated issues. Maintaining appropriate boundaries arises from the nature of the client-nurse relationship. Similar to other professional relationships, the client trusts the nurse who holds expertise, proficiency, and power — yet the client remains vulnerable as long as they have a need that the nurse has the capability to meet.

Owing to the client's vulnerability, nurses need awareness of their own power and must ensure that their practice aims to satisfy the client's nursing care needs. It is therefore not appropriate to perceive the maintenance of limits as an impediment to professional relations; rather, boundaries should be viewed as a facilitator of professional relationships (Justice, 1995). Professional boundaries protect the safe space that exists within the relationship and subsequently foster the creation of trust, which is essential in enabling clients to express their nursing care needs clearly.

In the last decade, Malaysia has witnessed unprecedented increases in the number and variety of new nursing roles, such as acute care nurse practitioners, advanced case managers, and clinical nurse specialist practitioners (Puteri, 2009). However, these new roles have largely emerged in acute care hospital environments. Research suggests that the increase in demand for, and change of, nursing roles will continue into the 21st century, with an expansion of nursing roles in ambulatory and community environments. Several studies suggest that the primary driver of this increase is the growing demand for nursing care alongside advancing nursing practice (Offredy, 2000).

Changing Roles of Nurses

Recent changes in healthcare roles in Malaysia have called for the maintenance of professional boundaries, in addition to the upholding of nursing laws and ethics. Litigation connected to negligence and confidentiality has affected the role of nurses (Puteri, 2009). The Malaysian nursing law does not adequately address the numerous legal and ethical challenges that require a comprehensive set of laws identifying the broad intersection between legal and ethical judgments. Technological advances in healthcare have also contributed to issues within the Malaysian nursing profession, which in turn has led to further changes in nursing roles.

Nurses are central to the provision of healthcare services between patients and hospitals, communities, and healthcare systems. Owing to the rapidly changing health environment in Malaysia, nurses have taken on extended roles to supplement services provided by other healthcare professionals. This extension of roles has required nurses in Malaysia to engage in activities that may carry individual legal consequences. As a result, nurses have reflected on their practices and have recognized the importance of a solid grounding in legal and ethical codes, thereby promoting competency when making complex decisions independently.

Professional boundaries are vital elements in the daily roles of nurse practitioners (NPs), as they provide for sound personal connections between patients and nurses. Similar to the situation for doctors, the difference in authority generated by the NP's rank and the patient's vulnerability creates the need to uphold safe professional boundaries (Hung, 1995). Boundaries can be breached through various means, including inappropriate relationships, giving or accepting gifts, physical or psychological abuse, and romantic or sexual relationships. Although many NP programs do not explicitly define professional boundaries, maintaining them is relevant to NP practice as an approach to avoiding confusion in daily clinical work.

Possible clinical situations that might call for professional boundaries include the following examples. In one scenario, a childhood friend of an NP asks the practitioner to act as her mother's healthcare provider. This worries the NP regarding the risk of missing a diagnosis in someone who is personally close to them. In another scenario, a clinic nurse manager mentions that one of the patients is a close friend of the senior director who employed the NP. The NP makes it known to the manager that this represents an uncomfortable situation, since all patients must be treated equally.

Evidence: Relevance of Professional Boundaries

Dual relationships arise when additional personal or professional demands, stresses, or concerns enter the provider-patient relationship. Professional boundaries define the personal connection existing between the patient and the practitioner, supporting the level of comfort that upholds personal dignity and promotes appropriate interactions for both the patient and the NP (Hung, 1995). Although there is limited empirical evidence documenting specific unacceptable behaviors, NPs are not immune to the challenges and temptations faced by other professionals.

A recent survey evaluating professional liabilities among NPs revealed that 1.4% of allegations arose from violations of professional boundaries, with a majority of violations resulting from sexual misconduct. It is important to note that while sexual misconduct represents one potential boundary violation, dating or showing preference to particular patients also constitutes a violation of professional boundaries (Goolsby, 2004). Given the large proportion of women working as NPs, it is appropriate to recognize particular vulnerability when addressing uncomfortable situations.

Prior studies suggest that a disparity in authority is inherent within patient-provider relationships, defining the professional's power alongside the patient's vulnerability. In a clinical setting, NPs access patients' personal disclosures, perform intimate procedures, and handle confidential information (Sheets, 2001). Although patients expect the NP to work within a professional framework, they often do not fully realize their own vulnerability. For this reason, NPs must recognize that illicit relationships with patients are never appropriate, and it remains the NP's responsibility to maintain professional boundaries regardless of the patient's wishes.

Overall, professional boundaries do not aim to create a distant relationship between NPs and their patients. They are relevant in NP practice just as they are in any other professional practice (Watson and Foster, 2003), and they aim to support the significant elements of the NP-patient relationship, including trust, compassion, respect, and empathy. Many studies suggest that NPs are valued professionals because they listen carefully to their patients and take time with them — attributes that are entirely consistent with maintaining professional boundaries (Goolsby, 2004).