It may not be reproduced for commercial use or sale. Reproduction for purposes other than those indicated above requires a licence or written permission, which may be obtained from the Australian Nursing and Midwifery Council. Requests and enquiries concerning reproduction rights should be addressed to the Australian Nursing and Midwifery Council PO Box 873 Dickson ACT 2602. A nurse’s guide to professional boundaries was first published in February 2010. Australian Nursing and Midwifery Council PO Box 873 Dickson ACT 2602 T +61 2 6257 7960 F +61 2 6257 7955 www. nmc. org. au PROFESSIONAL PRACTICE FRAMEWORK Contents Introduction What are professional boundaries? Professional boundaries at the over involvement end of the continuum Guiding principles for safe, professional practice Decision making tool—professional boundaries
Q & A—professional boundaries References 1 2 4 6 8 10 13 PROFESSIONAL PRACTICE FRAMEWORK ii A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework ii Introduction The Code of Professional Conduct for Nurses in Australia1, the Code of Ethics for Nurses in Australia2, the Code of Conduct for Nurses (New Zealand)3 and the New Zealand Nurses Organisation Code of Ethics4 set minimum standards in the respective regulatory jurisdictions that nurses are expected to uphold both within and outside of professional domains in order to ensure the ‘good standing’ of the profession in Australia and New Zealand. These two sets of companion Codes, together with other published practice standards (e. g. ompetency standards, decision making frameworks, direction and delegation guidelines and position statements) provide a framework for legally and professionally accountable and responsible nursing practice in all clinical, management, education and research domains, in Australia and New Zealand. These guidelines are designed to be read in conjunction with the above Codes and provide more detailed guidance and discussion in relation to the sometimes challenging area of managing professional boundaries; that is, identifying and differentiating the boundaries between professional relationships and personal relationships.
In doing so, these guidelines aim to protect the community by helping to prevent distress, confusion, harm or abuse of people being cared for by nurses. It is intended this resource will stimulate reflection, stimulate discussion and guide decision making in all aspects of the relationship that is established when care is provided by nurses to people in the course of their professional role, in all practice settings.
FRAMEWORK PROFESSIONAL PRACTICE Companion documents to these guidelines include a more detailed background discussion paper that includes further information on professional boundaries including references for the material used in these guidelines; and stories and scenarios that give examples of situations highlighting potential and real professional relationship and boundaries dilemmas for nurses. For nurses who also practise as midwives a separate but consistent set of guidelines has been developed for midwives to complement the equivalent codes of professional onduct and ethics for midwives in New Zealand and Australia. PROFESSIONAL PRACTICE FRAMEWORK iv A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework 1 What are professional boundaries? A nurse enters a therapeutic relationship with skills and knowledge that include a great deal of personal information about the individual in their care; and the authority to provide the care required by the individual.
The community trusts that nurses will act in the best interest of those in their care and that the nurse will base that care on an assessment of the individual’s specific needs. The power imbalance present in a professional relationship places the recipients of care in a position of vulnerability and of potential exposure to exploitation or abuse if that trust is not respected. Nurses have a responsibility to ensure that a relationship based on plans and goals that are therapeutic in intent and outcome is maintained.
This means that it is the responsibility of the nurse to maintain their professional and personal boundaries, as well as assisting colleagues and the people in their care, in maintaining theirs. Professional boundaries in nursing are defined as limits which protect the space between the professional’s power and the client’s vulnerability;5 that is they are the borders that mark the edges between a professional, therapeutic relationship and a non-professional or personal relationship between a nurse and a person in their care.
When a nurse crosses a boundary, they are generally behaving in an unprofessional manner and misusing the power in the relationship. 6 In order to manage these professional boundaries we need to appreciate that: PROFESSIONAL PRACTICE FRAMEWORK An inherent power imbalance exists within the relationship between people receiving care and nurses that make the persons in their care vulnerable and open to exploitation.
Nurses actively preserve the dignity of people through practiced kindness and respect for the vulnerability and powerlessness of people in their care… This vulnerability creates a power differential in the relationship between nurses and persons in their care that must be recognised and managed. 7 A diagram representing a continuum of professional behaviour provides a picture of therapeutic versus non-therapeutic behaviour in the relationship between the nurse and the persons in their care. 8 A CONTINUUM OF PROFESSIONAL BEHAVIOR
DISINTERESTED NEGLECTFUL under involvement THERAPEUTIC RELATIONSHIP zone of helpfulness BOUNDARY VIOLATIONS over involvement Every nurse-client relationship can be plotted on the continuum of professional behaviour Adapted from: National Council of State Boards of Nursing (2004) The ‘zone of helpfulness’ describes the centre of a continuum of professional behaviour. This zone is where the majority of interactions between a nurse and a person in their care should occur for effectiveness and the safety of that person. Over involvement’ of a nurse with a person in their care is to the right side of the continuum; this includes boundary crossings, boundary violations and sexual assault and inappropriate relationships with the partner or family of a person in the nurses care. ‘Under involvement’ lies to the left side of the continuum; this includes distancing, disinterest, coldness and neglect. This is also likely to be detrimental to the person in the nurse’s care.
Whilst these behaviours can be seen also as boundary issues, in regulatory terms, these behaviours tend to be reported to and dealt with by Nursing and Midwifery Regulatory PROFESSIONAL PRACTICE FRAMEWORK Authorities as professional misconduct issues. For this reason they are not discussed here in detail as the focus of the document is on the over-involvement end of the continuum. There are no definite lines separating the zone of helpfulness from the ends of the continuum; instead it is a gradual transition with ‘fuzzy’ edges. Context refers to the environment in which nursing is practised, and which in turn influences that practice. It includes: » » » » the characteristics of the consumer (including their cultural background) and the complexity of care required by them; the model of care, type of service or health facility and physical setting; the amount of clinical support and/or supervision that is available; and the resources that are available, including the staff skill mix and level of access to other health care professionals. 10
Nurses must always obtain informed consent from persons in their care prior to undertaking any therapeutic, professional interaction. 2 A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework 3 Professional boundaries at the over involvement end of the continuum11 Professional boundaries separate the therapeutic behavior of the nurse from any behavior, well intentioned or not, that could lessen the benefit of care to people, families and communities.
Boundaries give each person a sense of legitimate control in a relationship. Professional boundaries are the limits to the relationship of a nurse and a person in their care which allow for a safe, therapeutic connection between the nurse and that person (and their nominated partners, family and friends). The power of the nurse comes from the professional position and their access to private knowledge about the person in their care. Establishing boundaries allows the nurse to manage this power differential and allows a safe connection to meet the person’s needs.
Professional relationships exist only for the purpose of meeting the needs of the person in a nurse’s care. Boundary crossings are brief excursions across boundaries that may be inadvertent, thoughtless or even purposeful if done to meet a special therapeutic/care need. Boundary crossings can result in a return to established boundaries but should be evaluated by the nurse for potential consequences and implications to the person who is or has been in their care. Repeated boundary crossings should be avoided. Boundary violations can result when nurses confuse their needs with the needs of the person in their care.
Such violations are characterised by excessive personal disclosure by the nurse, secrecy or even a reversal of roles. Boundary violations can cause distress for the person who is or has been in the care of the nurse. This may not be recognised or felt by them until an event or other harmful consequences occur, which can be much later. Sexual misconduct is an extreme form of boundary PROFESSIONAL PRACTICE FRAMEWORK violation and includes any behaviour that is seductive, sexually demeaning, harassing or reasonably interpreted as sexual by the person who is in a therapeutic relationship with a nurse. Sexual misconduct is sexual assault.
Sexual misconduct by a nurse is an extremely serious violation of the nurse’s professional responsibility to the person in their care. Even if the person (or their legal representative) consents, or the person initiates the sexual conduct it is still the nurse’s responsibility to maintain the professional boundary in the relationship. PROFESSIONAL PRACTICE FRAMEWORK 4 OVER INVOLVEMENT A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework 5 Guiding principles for safe, professional practice12
CONTEXT THERAPEUTIC & CARE RELATIONSHIPS 10. The priority for nurses is planning care around meeting the therapeutic and care needs of persons entrusted to their care. 11. Nurses do not withhold care from a person as a punishment and recognise that any intent to cause pain or suffering as a retaliatory action in response to the behaviour of a person in their care is improper and unprofessional. 12. Nurses reflect on their own needs, behaviours, values and attitudes and beliefs and are conscious of their potential impact in therapeutic and professional relationships with people in their care. 13.
Nurses are aware of the inherent power imbalance in therapeutic and care relationships, knowing that coercing a person’s compliance may be an abuse of power. 14. Nurses are aware of and have the ability to validate the therapeutic or care purpose of their actions; and take into consideration the person’s preferences and responses to those actions. PROFESSIONAL PRACTICE FRAMEWORK 15. Nurses are aware of the potential for personal discomfort for both the person receiving care and themselves when care involves touching, holding, other personal contact or invasion of personal space; and respond appropriately.
DUAL RELATIONSHIPS & BOUNDARIES 1. Care is optimised when nurses and persons receiving care do not engage in dual relationships, for example where the nurse has a personal or business relationship, as well as a professional one with that person. Where dual relationships in therapeutic care situations are unavoidable nurses are aware of the potential for harm and take all steps to minimise the risks. Nurses establish and maintain the boundaries in their professional relationships with persons receiving care; and where necessary communicate these to that person.
Nurses recognise variables such as the care setting, community influences, the needs of the person and the nature of care or therapy they require affect the delineation of boundaries and respond accordingly. Nurses understand the complexities if personal relationships develop once professional relationships end as the person may need additional carePRACTICE making it difficult PROFESSIONAL and services; FRAMEWORK to determine when the professional relationship is truly terminated. Nurses examine any boundary crossing, and are aware of the potential implications, avoiding repeated crossings.
Nurses seek support and guidance from professional leaders when they have concerns relating to boundaries in therapeutic relationships. 2. 3. 4. 5. 6. 7. ACCESS TO OR THE DISCLOSURE OF INFORMATION 8. Nurses treat personal information obtained in a professional capacity as confidential; and do not use confidential information or their position of power to advantage themselves in any way. Nurses carefully consider their motives for disclosing personal information. Self-disclosure is limited to revealing information that has therapeutic or care value and only occurs within an established therapeutic or care relationship.
GIFTS, SERVICES & FINANCIAL RELATIONS > Nurses recognise that involvement in financial transactions (other than in a contract for the provision of services) and the receipt of anything other than ‘token gifts’ within professional relationships with persons in their care is likely to compromise the professional relationship. 9. 6 A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework 7 Decision making tool—professional boundaries13
CONTEXT PROPOSED BEHAVIOUR OR ACTIVITY YES Is the behaviour or activity consistent with the Codes of professional conduct and ethics for nurses in Australia & New Zealand? QUESTIONS FOR REFLECTION > Is the nurse doing something the person needs to learn to do themselves? Whose needs are being met—the person’s requiring care or the nurse’s? Will performing this activity cause confusion regarding the nurse’s role? Is the behaviour such that the nurse will feel comfortable in their colleagues knowing they had engaged in this activity, behaved in this way with a person in their care? NO
ABSTAIN FROM BEHAVIOUR > YES Does the behaviour or activity meet a clearly identified therapeutic need for the person requiring or receiving care? Is it part of their care plan? Is it in the person’s best interests? > NO ABSTAIN FROM BEHAVIOUR > YES Is the behaviour or activity within the scope of practice of the nurse; and, in keeping with contemporary competency and practice standards? NO ABSTAIN FROM BEHAVIOUR YES PROFESSIONAL PRACTICE FRAMEWORK Does the organisation have a policy in relation to the behaviour or activity? Can other/external resources be used to meet the need?
How does the context affect the carrying out of this activity eg setting, dual relationship? PROFESSIONAL PRACTICE FRAMEWORK NO ABSTAIN FROM BEHAVIOUR YES Are you competent to perform this activity? Do you understand your level of accountability in performing this activity? NO Discuss with a more senior colleague NO ABSTAIN FROM BEHAVIOUR YES PROCEED WITH THE BEHAVIOUR/ACTIVITY & DOCUMENT COMPREHENSIVELY YES 8 A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework Q & A—professional boundaries14 How can a nurse identify a potential boundary violation? Some behavioural indicators can alert nurses to potential boundary issues, for which there may be reasonable explanations. However, nurses who display one or more of the following behaviours should examine their professional relationships for possible boundary crossings or violations. Excessive self? disclosure—The nurse discusses personal problems, feelings of sexual attraction or aspects of his or her intimate or personal life with a person in their care.
Secretive behaviour—The nurse keeps secrets with the person receiving care and/or becomes guarded or defensive when someone questions their interaction. ‘Super nurse’ behaviour—The nurse believes that they are immune from fostering a non-therapeutic relationship and that only they understand and can meet the person’s needs. Singled? out treatment or person paying attention to the nurse—The nurse spends inappropriate amounts of time with a particular person in their care, visits the person when off-duty or swaps roster allocations to be with the person.
This form of treatment may also be reversed, with the person paying special or inappropriate attention to the nurse. PROFESSIONAL PRACTICE FRAMEWORK Selective communication—The nurse fails to explain actions and aspects of care to colleagues, reports only some aspects of the behaviour of the person in their care or gives ‘double messages’. In the reverse, the person receiving care returns repeatedly to the nurse, reasoning why they cannot approach other nursing staff e. g. they are ‘too busy’ Flirtations—The nurse communicates in a flirtatious manner, perhaps employing sexual innuendo, off-colour jokes or offensive language. You and me against the world’ behaviour—The nurse views the person in their care in a protective manner, tends not to accept the relationship with the person as only a professional relationship or sides with the person’s position regardless of that position and its implications. Sexual misconduct/assault—The nurse fails to recognise the development of an attraction of a sexual nature for the person receiving care or between themselves and the person in their care. What are some of the nursing practice implications of professional boundaries?
Nurses need to practice in a manner consistent with the Codes of professional conduct and ethics for nurses in Australia and New Zealand and other relevant professional standards. Nurses should be knowledgeable regarding professional boundaries and work to establish and maintain those boundaries. Nurses should examine any boundary-crossing behaviour and seek assistance and counsel from their colleagues and supervisors when such crossings occur. What if a nurse lives in a small community? Does this mean that they cannot interact with neighbours or friends?
Variables such as the care setting, community influences, client needs, nature of the therapy provided, age of the client and degree of involvement affect the delineation of behavioural limits. All of these factors must be considered when establishing boundaries; and all contribute to the complexity of professional boundaries. The difference between a caring relationship and an over-involved relationship is narrow. A professional living and working in a remote community will, out of necessity, have business and social relationships with people to whom they are providing care.
Setting appropriate standards is very difficult. If they do not relate to real life, these standards may be ignored by the nurse or simply may not work. However, the PROFESSIONAL PRACTICE FRAMEWORK absence of consideration of professional boundaries places person receiving care and the nurse at risk. What should a nurse do if confronted with possible boundary violations or sexual misconduct in a colleague? The safety of people requiring or receiving care must be the first priority. The nurse needs to be prepared to deal with violations by any member of the health care team.
If a person’s behaviour is ambiguous, or if the nurse is unsure of how to interpret a situation, the nurse should consult with a trusted supervisor or colleague. Incidents should be thoroughly documented in a timely manner. Nurses should be familiar with reporting requirements, as well as the grounds for discipline under the health professional regulatory scheme, and they are expected to comply with the legal and ethical mandates for reporting. 10 A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework
A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework 11 What if a person in their care offers a nurse, for example, bus fare or meal tickets? There are two issues here. Firstly the nurse may have been inappropriately disclosing personal information about their private circumstances while providing care to the person which is inconsistent with the professional conduct of a nurse. Secondly, the acceptance by a nurse of money or goods from a person in their care is inappropriate in all circumstances.
Acceptable Gifts Where nurses work in organisations, consideration should be given to the development of policy in relation to gifts. Individual organisational policy should decide the value at which items need to be officially declared. Gifts such as chocolates or flowers are generally acceptable. The process of declaring gifts received prompts nurses to consider the issue of gifts and professional conduct and acts as a stimulus to discussion around what is appropriate and what is not. References 1 Australian Nursing and Midwifery Council (2008) Code of Professional Conduct for Nurses in Australia, Canberra.
Available at: www. anmc. org. au. Australian Nursing and Midwifery Council, Australian Nursing Federation, Royal College of Nursing Australia (2008) Code of Ethics for Nurses in Australia, Canberra. Available at: www. anmc. org. au. Nursing Council of New Zealand (2008) Code of conduct for nurses, Wellington. Available at: http://www. nursingcouncil. org. nz/ code%20of%20conduct%20March%202008. pdf. New Zealand Nurses Organisation (2001) New Zealand Nurses Organisation Code of Ethics, Wellington. Peterson M (1992) At Personal Risk: Boundary violations in professional? client relationships, WW Norton & Co, New York.
College of Registered Nurses of British Columbia (2006) Nurse? Client Relationships, Pub No 406, Vancouver, 6. Available at: www. crnbc. ca. Conduct Statement 8, Explanation 1—Code of Professional Conduct for Nurses in Australia. College & Association of Registered Nurses of Alberta (2005) PROFESSIONAL Discussion Guide and Teaching Tool, Professional Boundaries: A PRACTICE FRAMEWORK Edmonton, September, 2. Available at: www. nurses. ab. ca. National Council of State Boards of Nursing (2007) Professional Boundaries: A nurse’s guide to the importance of appropriate professional boundaries, Chicago, 4.
Available at: www. ncsbn. org. 2 3 4 5 6 7 8 PROFESSIONAL PRACTICE FRAMEWORK 9 10 Adapted from Adapted from: ANMC (2007) A national framework for the development of decision—making tools for nursing and midwifery practice. 11 Adapted from National Council of State Boards of Nursing (2007) Professional Boundaries: A nurse’s guide to the importance of appropriate professional boundaries, Chicago, 3. Available at: www. ncsbn. org. 12 A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework
A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework 13 12 Nursing Council of New Zealand (2008) Code of conduct for nurses, Wellington; New Zealand Nurses Organisation (2001) New Zealand Nurses Organisation Code of Ethics, Wellington; Australian Nursing and Midwifery Council (2008) Code of Professional Conduct for Nurses in Australia Canberra; Australian Nursing and Midwifery Council, Australian Nursing Federation, Royal College of Nursing Australia (2008) Code of Ethics for Nurses in Australia, Canberra.
Both available at: www. anmc. org. au; The University of Newcastle (2007) A Project Report on the Development of ANMC Guidelines on Professional Boundaries for Nurses ; and Draft National Guidelines on Professional Boundaries for Nurses , October; and National Council of State Boards of Nursing (2007) Professional Boundaries: A nurse’s guide to the importance of appropriate professional boundaries, Chicago, 4. Available at: www. ncsbn. org. 3 Adapted from: ANMC (2007) A national framework for the development of decision? making tools for nursing and midwifery practice; College of Registered Nurses of Nova Scotia (2002) Guidelines for Nurse? Client Relationships, Halifax, 5; College of Nurses Ontario (2006) Practice Standard: Therapeutic Nurse? Client Relationship, Toronto, 11. 14 Adapted from National Council of State Boards of Nursing (2007) Professional Boundaries: A nurse’s guide to the importance of appropriate professional boundaries, Chicago, 6–9.
Available at: www. ncsbn. org. PROFESSIONAL PRACTICE FRAMEWORK PROFESSIONAL PRACTICE FRAMEWORK 14 A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework 15 PROFESSIONAL PRACTICE FRAMEWORK 16 A nurse’s guide to professional boundaries is a component of the ANMC Professional Practice Framework