Professional Boundaries in Nursing: Ethics, Law & Social Media

Introduction

The nursing profession consistently ranks among the most widely trusted and respected professions (NCSBN, 2018). Such rankings reflect the special relationship that exists between nurses and those under their care. A patient will normally expect a nurse to act in a manner that serves their best interest and respects their dignity. This expectation creates both an ethical and legal obligation: nurses must abstain from achieving personal benefit at the expense of the patient and must not jeopardize the therapeutic nurse-patient relationship (Wiles, 2011). To successfully maintain that trust and practice within professional requirements, a nurse must possess relevant knowledge of professional boundaries and consistently uphold them (Slobogian, Giles & Rent, 2017).

This paper discusses professional boundaries for the nursing profession, particularly in the age of social media, and examines how nurses can effectively maintain trust and respect from those under their care by observing professional standards. The paper is intended for a multidisciplinary healthcare team. It presents theoretical underpinnings on the issue and concludes with a systems-level program addressing the problem of professional boundary violations.

Statement of the Problem

Patients look to healthcare professionals for their wellbeing and the alleviation of illness. Among the various healthcare professionals a patient interacts with, the nurse typically has the longest contact per session and over time, and the relationship is often more personal. As a result, a patient may want, seek, or expect more from the nurse than a strictly clinical relationship permits (Angelini et al., 2018). On the other hand, the enormous responsibility nurses carry—and their desire to help patients recover and relieve suffering—may cause a nurse to want to do more than their professional role requires (Gellerstedt et al., 2019). This dynamic is especially common among new nurses, nursing students on internship, or nurses caring for people they know personally.

This complex relationship is further complicated by social media platforms, where patients or their family members can search for nurses online and send friend requests. Social media introduces an entirely new concern to nurse-patient relationships. Through these platforms, a patient or family member can learn personal details about a nurse—for those nurses who are active on social media—which can influence both parties' expectations in ways that undermine professional boundaries.

Acting beyond professional boundaries is both an ethical and legal concern. Professional boundaries emerge from the space between the power held by the nurse and the vulnerability of the patient—power that derives from the nurse's professional position and access to sensitive personal information (NCSBN, 2018). The nurse-patient relationship is inherently asymmetrical: the nurse typically knows significant personal information about the patient, while the patient knows little or nothing about the nurse. This asymmetry gives rise to a legal concern governed by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (Daigle, 2020). Acting outside of professional boundaries can therefore create legal jeopardy for both the individual nurse and the healthcare organization.

Professional boundaries in healthcare, especially in nursing, are an indispensable cornerstone of establishing and maintaining therapeutic relationships with patients and their families (Slobogian et al., 2017). Boundary crossing is often unplanned and driven by genuinely positive intentions—an honest effort to meet a patient's needs, or vice versa. Across various jurisdictions, professional bodies have established and enforced codes of conduct: the Code of Professional Conduct for Nurses in Australia is governed by the Nursing and Midwifery Board of Australia; the American Nurses Association maintains a nursing code of ethics; and in the United Kingdom, the Nursing and Midwifery Council governs The Code. While these frameworks underscore the importance of nursing ethics, professional boundaries remain particularly significant because violations tend to follow a slippery slope. There is a thin line between neglect on one end and over-involvement on the other, as illustrated in the continuum of professional behavior (Nursing and Midwifery Board of Australia, 2010). For many nurses, the zone of helpfulness may be threatened by factors such as inexperience, changing care needs, personal attributes like empathy, or a prior relationship with a patient. Crossing professional boundaries exposes the nurse to both ethical and legal repercussions. The literature reviewed for this research confirms that social media has significantly complicated professional boundaries (Ashton, 2016), making this a topic that warrants serious academic attention.

Figure 1: Continuum of professional behavior (Adopted from Nursing and Midwifery Board of Australia, 2010)

Professional Boundary Theory

Professional boundaries serve as a safeguard for both the patient and the nurse. They allow for the progression of a therapeutic relationship and enable the nurse to contain and adequately process all feelings without acting on them inappropriately. The psychodynamic terms countertransference and transference are used to describe the emotional responses of the professional and the patient to each other, respectively (Jones, Fitzpatrick & Rogers, 2016). The ability to manage transference and countertransference is essential to maintaining professional boundaries and delivering appropriate nursing care. One criticism of this framework is that countertransference is more of a reactive experience than a subjective one. Gutheil and Gabbard (1998) draw an important distinction between boundary crossing—which does not harm the patient—and boundary violation, which is exploitative or harmful. This distinction has been widely regarded as a turning point for the field of boundary theory.

According to Unhjem (2019), the concepts of non-exploitation of the patient, abstinence, neutral practice by the nurse, and avoidance of dual agency can be traced to Sigmund Freud. These concepts are connected to the nurse's role and vary depending on context and the type of therapeutic setting. For example, the boundary considerations facing a nurse in a small rural town differ greatly from those facing a nurse practicing in a large urban metropolis.

The terms self-disclosure and dual relationship describe two additional dimensions of boundary theory. Self-disclosure refers to the sharing of personal information by the nurse and is considered integral to humanizing the nurse-patient relationship and building trust (Unhjem, 2019). Self-disclosure has become a particularly important research concern in the age of social media, as patients or their family members can access personal information about a nurse through social media platforms, shaping their perceptions of that nurse. For example, a family member might request that the hospital administration assign a different nurse to their relative after learning from social media that the current nurse has a family member with chronic illness—reasoning, perhaps incorrectly, that this could affect the quality of care provided (Slobogian et al., 2017).

The dual relationship, by contrast, is closely associated with sexual boundary violations, a phenomenon that peaked in the 1980s and early 1990s (Gutheil & Brodsky, 2011). Dual relationships can range from relatively harmless transgressions to serious sexual boundary violations. Sexual relationships with patients currently under a nurse's care are considered a prosecutable offense and are clearly unprofessional. The question of sexual relationships with former patients remains more contested in the literature. While some authors have characterized sexual transgressions as comparatively minor boundary violations (Unhjem, 2019), they nonetheless constitute boundary violations capable of attracting legal consequences.

Conclusion

This proposed program is to be audited and revised accordingly to address emerging organizational and industry ethical issues concerning nurse professional boundaries. The audit will be conducted by all team members (the stakeholders involved in implementing the program). Auditing will measure how effectively nurses manage professional boundaries, identify areas of concern, and track emerging technologies and industry trends that require additional attention.

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Application to Individual Justice

Professional boundaries benefit both the patient and the nursing practitioner by guiding and defining the nurse-patient relationship. They function as frameworks for organizational ethics and as legal protections for nurses and patients alike (NCSBN, 2018). When complications arise in professional practice, the concerned parties can refer to established professional boundaries to evaluate whether any excess or deficiency occurred. In this way, professional boundaries serve as guarantors of social justice for all parties, with particular emphasis on protecting both nurse and patient.

For the patient, professional boundaries define the scope within which the nurse's interactions should be confined. In the event of a violation, the patient may seek legal redress through the courts. In such cases, the nurse and the healthcare facility must defend themselves, and the adjudicating body will rely on established professional and ethical boundaries to determine whether a violation occurred. Conversely, if a patient or family member requests special treatment—or attempts to provide a nurse with gifts or other extraordinary benefits—the nurse and the healthcare facility can, by invoking professional ethical boundaries, decline those requests. For instance, if a family member requests the transfer of a nurse on the grounds of personal challenges the nurse is experiencing, the healthcare organization may decline that request provided it can determine that the nurse remains capable of rendering unimpaired professional care.