Of all the things you have to earn to be a nurse — your degree, your license, your job — your patients’ trust is one of the most important. They rely on you to be honest and ethical and to put their needs above your own. Your patients’ trust is what allows you to be good at what you do. It’s tough to gain and easy to lose, which is why it’s so important to strive to keep things professional at all times.
But setting professional boundaries as a nurse can be a struggle. Things can get fuzzy, and sometimes pushing limits is the right call. In the end, setting and maintaining boundaries means protecting your patient, being honest with yourself about your motivations, and following your instincts.
What Do ‘Professional Boundaries’ Mean in Nursing?
As the National Council of State Boards of Nursing (NCSBN) puts it, professional boundaries are “the spaces between the nurse’s power and the patient’s vulnerability.” They are rules or limits you set for yourself to protect your patients, your own safety, and your job. NCSBN adds that “the power of the nurse comes from the nurse’s professional position and access to sensitive personal information. The difference in personal information the nurse knows about the patient versus personal information the patient knows about the nurse creates an imbalance in the nurse-patient relationship. Nurses should make every effort to respect the power imbalance and ensure a patient-centered relationship.”
Boundary-Crossing vs. Boundary Violations
As important as professional boundaries are, sometimes momentarily stepping over them can be harmless, or perhaps even beneficial for your patient, NCSBN says. For example, when your patient is going through a hard time, telling a personal story about a similar experience can make them feel like you understand what they’re going through. You’re temporarily crossing a boundary because you think it will help them move forward with their care.
Boundary violations, on the other hand, damage the nurse-patient relationship and put your patient’s care in jeopardy. When you say or do something that makes the patient uncomfortable or confuses them about the nature of your relationship, it compromises your ability to care for them effectively. It’s a hard thing to come back from.
Boundary-Crossing vs. Boundary Violations
| Examples of Crossing Boundaries | Examples of Violating Boundaries |
|---|---|
| You tell a patient who is deciding whether to vaccinate her child a personal story of your child getting sick with a vaccine-preventable disease and how it informed your decision to vaccinate in the future. | You tell a patient about your child's personal health issue because you are upset and seeking comfort. |
| You accept a small plate of food from a patient while providing in-home care to avoid offending them. | You accept money from a patient to pay your bills. |
| You call a patient when you’re at home because you’re worried they might be having a difficult time following their care plan. | You invite your patient out for drinks after your shift ends. |
Why Do Nurses Need to Set Boundaries With Patients?
There’s a natural power imbalance in nursing, says Keith (“Nurse Keith”) Carlson, RN BSN, NC-BC. You know more about your patients than they know about you. But maintaining that imbalance isn’t a power trip; it’s essential to your patient’s care. The nurse-patient relationship should be focused exclusively on the patient, and you need them to respect your authority enough to follow your care instructions. Get too cozy, and you could put their care (not to mention your job) at risk.
5 Examples of Boundary Violations in Nurse-Patient Relationships
While some boundary violations (like sexual misconduct) are obvious, there are others that you might not realize are violations until it’s too late:
Example #1: Sharing too much, or for the wrong reasons.
Telling a brief personal story when your patient is upset is one thing, but revealing too many personal details or sharing an anecdote because you’re looking for solace is something else entirely. Over-sharing can make your patient uncomfortable and chip away at your professional authority.
Example #2: Giving or accepting gifts.
When you’ve spent a lot of time with someone, it’s natural to want to show gratitude or affection through gifts. In home health situations, in particular, your patient might start to view you as part of the family. But you’re not family. You’re a professional who has been hired to care for them, and exchanging gifts can shift expectations about what you’re there to do or what your intentions might be. That said, there are some exceptions to this, Carlson says. If rejecting a small token — like a cup of tea or a small plate of food — might offend your patient, then it’s probably OK to take it because accepting the gift is about protecting your relationship with your patient and not about your own personal gain.
Example #3: Blurring the lines on social media.
Blowing off steam on social media sites might feel like a good way to de-stress, but you have to be careful about what you post and where. Sharing personal commentary or protected information about patients online (violating HIPAA) could damage your professional reputation and cost you your job. That’s what happened in Houston when a nurse shared her thoughts about a measles patient on Facebook. She didn’t name the patient, but she had her employer listed on her public profile and measles was rare in the area. Screenshots were taken of her post and distributed online, gaining the attention of officials at the hospital where she worked. Between her description and publicly available information, her bosses worried she put the patient at risk, so they fired her.
Example #4: Exchanging money.
Unless part of your job is to accept money from patients for services rendered, exchanging money in any way (such as accepting monetary gifts, lending money, or getting reimbursed for purchases done as a favor) can be a minefield. Not only can it put you at risk for a conflict if the money isn’t returned, it can also set unrealistic expectations for the future and affect your professional reputation.
Example #5: Getting involved romantically (or giving that impression).
This one might be a no-brainer, but it’s important to reiterate. It doesn’t matter who initiates sexual contact or if it’s consensual, any sexual activity between a nurse and a patient is considered sexual misconduct, according to the NCSBN. But even giving the impression of romantic interest (even inadvertently) can affect the nurse-patient relationship, Carlson says. A nurse commenting on how nice a patient looks that day — especially if they are around the same age — could be perceived as a come-on and make the patient (or other patients) uncomfortable.
How to Know If You Crossed a Professional Boundary: 3 Questions to Ask Yourself
Because some patients need a more personal touch, the professional boundaries you establish might change depending on the circumstances. So how do you know when you’ve gone too far? That’s something every nurse has to feel out for themselves, Carlson says, and you can do that by asking some key questions:
1) Has your relationship with the patient changed?
Sometimes, it’s really obvious when something you said or did damaged your relationship with your patient. Other times, it’s more subtle — they’re a little less interested in what you have to say, for example, or they expect favors or gifts that they probably shouldn’t. Any shift in the winds could signal you’ve crossed a boundary.
2) Who is this really about?
Whatever the action (e.g., gifts, sharing a story, etc.), it can be helpful to take a step back and look at whether what you’re doing (or not doing) is really in the patient’s best interest. Are you sharing that story about your dad because you think it will help them? Or are you sharing it because you’re really seeking validation?
3) What does your gut tell you?
If you’re starting to get uncomfortable with what’s happening, that could be a red flag that the balance of power is shifting. Trust your instincts, Carlson says. If something feels over the line, it probably is.
4 Tips for Creating Nurse-Patient Boundaries
It’s helpful to think about boundaries as simple lines in the sand, but the NCSBN says it’s really more of a continuum. At one end, you have over-involvement (e.g., sharing too much of your personal life); at the other, you have under-involvement (e.g., being disinterested in or neglecting your patient). As a nurse, you want to strike a balance between the two extremes: warm but not too friendly, detached but not cold.
To do that, there are some things you should keep in mind, Carlson says, like:
1) Keep things patient-centered.
Everything you do as a nurse should be for the benefit of the patient you’re caring for. Ask yourself: “Am I doing this for the patient? How could this affect their care?”
2) Educate yourself.
Brush up on concepts like the therapeutic use of self to get a better understanding of when and how to share more of your personality for the good of the patient. And you also might want to familiarize yourself with the norms and customs of other cultures. For example, some cultures are touchy-feely, while others are more reserved. Knowing the differences in expectations can help you avoid violating boundaries inadvertently.
3) Get a second opinion.
Other nurses might have insight or experiences you don’t. If you’re not sure where the professional boundaries are, ask someone else for their perspective and guidance.
4) Go in with a game plan.
You won’t be able to prepare for everything, but taking a minute to think through some possible scenarios can help you stay in-bounds if you encounter them. For example, what would you do if a patient wants to give you an extravagant gift? What about a patient you find attractive or insulting? Come up with a plan and run through the different ways it could play out so you don’t cross any lines because you’re caught off-guard.
6 Tips for Handling Different Patient Scenarios
Maintaining Professional Boundaries With a Favorite Patient
You’re only human. It’s natural to like some patients more than others. But having a good rapport with someone can make it that much harder to stay within professional boundaries. You can help protect yourself (and your patient) by taking some precautions.
- Stay self-aware. Be honest with yourself about your feelings for the patient, and be extra mindful about what you say or do around them. Just because you’re comfortable around them doesn’t mean you can be complacent.
- Err on the side of caution. If you aren’t sure where the professional boundaries are, play it safe. Keep conversations light and to the point, and avoid any unnecessary touching.
Maintaining Professional Boundaries With an Uncooperative Patient
Some patients can make your job much more difficult. Maybe they’re overly rude to you, or they insist on ringing the bell every 20 seconds, or they’re just plain unpleasant to be around. Whatever the reason, you’ll have to fight the urge to avoid the patient or show your frustration. Here are some tips and tricks to help you do it:
- Check your baggage at the door. The patient might not be the only source of stress in your life. Take a minute to think about whether something else is really bothering you and whether it’s affecting how you view the patient or their actions.
- Remember to breathe. Frustrating or not, your patient needs you to keep your cool. If you’re getting flustered and are worried you might say something you regret, take some long, slow breaths to steady your nerves.
Maintaining Professional Boundaries With a Patient You Know Personally
When you already have a personal relationship with a patient, establishing professional boundaries can get tricky. Say you’re an oncology nurse caring for a good friend’s mom, and your friend asks you for protected health information. Taking some extra steps can help you keep things professional:
- Be clear about what will happen. Before caring for the patient, be honest with them (and yourself) about what your role is and what you can or can’t do as their nurse.
- Know when to walk away. If you’re finding yourself crossing boundaries too often or you feel like your relationship (personal or professional) is taking a hit, you might be too close to the situation. Find a way to transfer the care of your patient to another nurse.
6 Tips for Maintaining Professional Boundaries on Social Media
Interactions with patients aren’t limited to physical spaces. They can happen online, too. Even if you only use social media to connect with old friends or share photos of your kids, what you post could be seen by patients and negatively affect your professional relationships.
While you don’t have to swear off all social media altogether, there are some things you can do to keep your personal life personal when you post things online:
1) Avoid “friending” patients.
Don’t accept “friend” requests from patients or their families under any circumstances, Carlson says, and you might want to consider avoiding “friending” colleagues, too. A blanket policy like this can help you avoid blurring lines between the personal or professional.
2) Check your privacy settings.
Whatever the platform, make sure your settings are set to the maximum level of privacy allowed. Accounts on Facebook, Twitter, and Instagram, for example, can all be set up so that any new friends or followers has to first be approved by you.
3) Keep things uncontroversial.
Even if you have your privacy settings maxed out, those in your network can still screenshot your posts and share them elsewhere. So avoid posting about hot-button issues (ex. politics) that might get in the way of relationships with patients and colleagues, Carlson says. If you wouldn’t talk about it in person with a patient at their bedside, don’t post about it online.
4) Protect personal information.
Because nothing you post online is ever truly private, don’t share any information about patients that could be used to identify them or disclose their medical information. This could violate HIPAA, putting your patient and your job at risk.
5) Keep it civil.
Venting online about your overbearing boss or an uncooperative patient is risky and unprofessional. The remarks could get back around to (current and future) patients or colleagues and negatively affect your relationships with them.
There are a few exceptions to some of the above, Carlson says. For example, if you have professional social media pages or accounts to promote your business or yourself as a nursing professional, it’s OK for patients to “like” your professional page or “follow” you on other platforms. However, the same rules of content apply: Keep posts professional and be cautious when you engage with people who tag or post on your professional pages and accounts.
6 Resources Where You Can Learn More
Want to find out more about professional boundaries in nursing? These resources can help:
- A Nurse’s Guide to Professional Boundaries (NCSBN, 2018)
- Don’t Cross the Line: Respecting Professional Boundaries (CE Connection, 2012)
- Do You Know Your Professional Boundaries? (Nursing Made Incredibly Easy!, 2012)
- When Does a Nurse-patient Relationship Cross the Line? (American Nurse Today, 2007)
- Video: Professional Boundaries in Nursing (NCSBN, 2014)
- Video: Therapeutic Relationships in Nursing: The Professions' Perspective (Nurse Killam, 2013)
Image courtesy of iStock.com/PaulMaguire