Don't cross the line: respecting professional boundaries.

At best, nurses and patients develop a special bond based on trust, compassion, and mutual respect.

In most cases, professional standards of care and personal morals prevent inappropriate relationships from developing. But in some cases, the nurse-patient relationship develops into a personal relationship that can lead to inappropriate behavior.
 

Defining professional boundaries

According to the National Council of State Boards of Nursing (NCSBN), professional boundaries are “the spaces between the nurse’s power and the client’s vulnerability.”1 Unfortunately, setting boundaries isn’t straightforward. The Code of Ethics for Nurses states, “When acting within one’s role as a professional, the nurse recognizes and maintains boundaries that establish appropriate limits to relationships.2

Behaviors considered inappropriate can be separated into three categories: boundary crossing, boundary violation, and sexual misconduct.3 Nurses should visit their state board of nursing’s website to explore how the concepts of boundaries and sexual misconduct are defined in their own state.
 

Boundary crossing: caution

The NCSBN defines a boundary crossing as a decision to deviate from an established boundary for a therapeutic purpose.1 Examples include the nurse disclosing personal information to reassure the patient or accepting gifts from the patient. Home health nurses may help patients with tasks outside their job description, such as washing dishes or doing laundry. A hospital-employed nurse may visit a former patient after discharge to check on his or her progress.

Minor boundary crossings are generally acceptable when performed for a patient’s well-being. But seemingly trivial boundary crossings sometimes lead to more troublesome unprofessional behaviors.
 

Boundary violation: danger

Sometimes nurses cross professional boundaries for reasons that aren’t even arguably therapeutic to the patient. This is considered a boundary violation. Keeping a patient in the hospital when a qualified caregiver is available could fall under this category. Another example is the nurse disclosing the patient’s personal information, which violates the privacy provisions of the Health Insurance Portability and Accountability Act (HIPAA).
 

Sexual misconduct: forbidden

The NCSBN defines sexual misconduct as “engaging in contact with a patient that’s sexual or may reasonably be interpreted by the patient as sexual; any verbal behavior that’s seductive or sexually demeaning to a patient; or engaging in sexual exploitation of a patient or former patient.” 4 In addition, “kissing,” “suggesting or discussing the possibility of dating,” having a “sexual or romantic relationship prior to the end of the professional relationship,” or “soliciting a date with a patient, client, or key party” (immediate family members) are included under sexual misconduct.4
 

Identifying those at risk

Inexperienced or younger nurses may be at risk for committing boundary violations because of lack of experience or understanding. Some who violate boundaries may also have preexisting or underlying personal issues, such as substance abuse.5

Certain patients are also more susceptible to becoming victims of inappropriate behaviors. Significant and emotional life events can pose risks for patients as they become vulnerable to compassionate feedback and seek to connect with others who can empathize with them.
 

Recognizing warning signs

Signs of inappropriate behavior can be subtle at first. Early signs might include spending more time with a patient, showing favoritism, or meeting a patient in areas besides those used to provide direct patient care.6 As relationships progress, nurses may be more concerned about their own personal appearance when around the patient or become defensive when others ask about this patient interaction.5

Patients also demonstrate signs when involved in such a relationship. They may show dependence on a particular staff member, frequently request the same caregiver, or ask other staff questions about the nurse.
 

Confrontation and legalities

The duty to address inappropriate relationships extends not only to the nurse directly involved, but also to nurses who are peers or managers of the involved nurse.3 When a questionable situation or relationship is suspected, it’s every nurse’s duty to report it. State boards of nursing may include a provision that specifically requires that a nurse manager report inappropriate conduct to the board.

Blatant acts of sexual misconduct that are witnessed are always reportable to the nurse’s supervisor, the state board of nursing, and possibly even local law enforcement authorities depending on the state.4 Each state board of nursing creates policies about boundary crossing or sexual misconduct. Nurses are responsible for being familiar with and understanding their state’s provisions and laws.

When making a report, “thoroughly document dates, times, witnesses, circumstances surrounding the event, statements made, and actions taken. Don’t document suspicions or hearsay.”6 Everything documented should be objective; use direct quotes whenever possible. Documenting something that’s subjective or not a direct quote can put the writer at risk for a defamation action if the information isn’t true or accurate. Follow your facility’s policies and procedures for reporting suspicions or allegations of sexual misconduct.

When a sexual misconduct claim is made, the nurse or other healthcare professional can be subject to investigation by licensing boards and/or criminal and/or civil proceedings.5

If the nurse’s specific conduct (such as battery) is considered a felony or misdemeanor by the state, the nurse could face criminal liability. Civil actions can arise for battery or other harm suffered by the patient such as intentional infliction of emotional distress.

A patient can initiate a civil or criminal lawsuit against a nurse even if the sexual involvement took place after the nurse-patient relationship ended.4

State boards of nursing have the option to take immediate action (such as suspending the nurse’s license pending results of the investigation) to protect the public and separate a nurse from practice while an investigation is pending, take action based on the criminal conviction or disciplinary action that was taken in another jurisdiction, or decline to take formal action for a charge unless a formal investigation by the board of nursing provides evidence to substantiate the charges of misconduct. If and when such evidence is found, appropriate disciplinary action is taken in accordance with the state’s nurse practice act.4

Allegations of sexual misconduct can be difficult to defend. Damages and legal representation fees may not be covered by professional liability insurance. Damages can include medical bills, such as psychiatric and/or medical care sought as a result of the interaction between the nurse and patient, or for lost wages if the patient isn’t able to work as a result of the harm caused by the interaction. Pain and suffering can also be considered based on state law.

Settlements against healthcare providers or plaintiff verdicts can be recorded in the Health Integrity and Protection Data Bank, which can be used by individual healthcare providers, employers, and lawyers to investigate any charges that might have been made against an individual or hospital.7 The nurse’s name could be placed on a disqualified provider list for state Medicaid and/or federal Medicare programs or on a state’s sexual predator listing. Nurses on the disqualified provider list can’t be hired because the facility wouldn’t receive Medicare or Medicaid funds. Obtaining future employment as a nurse may be difficult, if not impossible, depending on the outcome of the case and whether the nursing license was suspended or revoked.
 

Steps to prevention

Education should start at the entry into practice level in nursing programs and then be continued in higher nursing education programs by employers, boards of nursing, and nursing associations. Within healthcare facilities, policies regarding sexual misconduct and boundary violations should be updated and made part of the staff’s annual education.5

The consequences of crossing over boundaries, especially those considered violations, can be devastating to both patients and healthcare professionals. With improved prevention and education, further research, and constant self-awareness, nurses can create a safe and therapeutic environment.
 

References

  1. NCSBN. A Nurse's Guide to Professional Boundaries. Chicago, IL: NCSBN; 2011.
  2. American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Association; 2001.
  3. Peternelj-Taylor CA, Yonge O. Exploring boundaries in the nurse-client relationship: professional roles and responsibilities. Perspect Psychiatr Care. 2003;39(2):55–66.
  4. NCSBN. Practical Guidelines for Boards of Nursing on Sexual Misconduct Cases. Chicago, IL: NCSBN; 2009. 
  5. Baca M. Sexual boundaries: are they common sense? J Nurse Pract. 2009;5(7):500–505.
  6. Smith LL, Taylor BB, Keys AT, Gornto SB. Nurse-patient boundaries: crossing the line. Am J Nurs. 1997;97(12):26–32.
  7. NCSBN. Healthcare Integrity and Protection Data Bank (HIPDB) and National Practitioner Data Bank (NPDB).

Adapted from “Don’t cross the line: Respecting professional boundaries,” by Angela F. Hanna, ASN, RN, and Patricia Dunphy Suplee, PhD, RNC-OB, originally published in the January 2013 issue of Nursing Management. ©2013 by Lippincott Williams & Wilkins, Inc.

Frequently Asked Questions

You have questions. We have answers. (It's why we're here.)



What kinds of activities might trigger a disciplinary action by a licensing board or regulatory agency? 


The fact is anyone can file a complaint against you with the state board for any reason—even your own employer—and it doesn’t have to be solely connected to your professional duties. All complaints need to be taken seriously, no matter how trivial or unfounded they may appear. 


How does a shared limit policy work?


A shared limit policy is issued in the name of your professional business or company. The policy provides professional liability insurance coverage for the business entity named on the certificate of insurance and any of the employees of the business entity, provided they are a ratable profession within our program. Coverage is also provided for locum tenens professionals with whom the business entity has contracted for services the locum tenens performs for the business entity.

The business, and all eligible employees and sub-contractors you regularly employ, will be considered when determining your practice’s premium calculation and share the same coverage limits you select for the business.


We have a shared limit policy. Are employees covered if they practice outside our office?


The policy covers your employees outside the office as long as they are performing covered professional services on behalf of your business.

If your employees are moonlighting, either for pay or as a volunteer, they should carry an individual professional liability insurance policy to cover those services. Otherwise, they might not be covered for claims that arise out of these activities.



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