This independent study has been developed for nurses who wish to learn more about professional boundaries and sexual misconduct relative to nursing practice.
OUTCOMES: The nurse will have enhanced knowledge of professional boundary issues as well as identify what a nurse should do if a boundary crossing or violation should occur.
1.4 contact hours of Category A (Law and Rules) will be awarded for successful completion of this independent study.
The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91)
Expires 11/1/2020
DIRECTIONS & CRITERIA FOR SUCCESSFUL COMPLETION:
1. Please read the below article carefully.
2. Complete the post-test, evaluation form and the registration form.
The post-test will be reviewed. If a score of 70 percent or better is achieved, a certificate will be sent to you. If a score of 70 percent is not achieved, a letter of notification of the final score and a second post-test will be sent to you.
We recommend that this independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be issued.
If you have any questions, please contact the Ohio Nurses Association’s CE department at sswearingen@ohnurses.org.
Originally developed by Jan Lanier, RN, JD, Previously reviewed by Kathleen Morris, MSA, BSN, RN, R. Wynne Simpkins, MS, RN and Cynthia Hasseman, MSN, Ed., RN. Revised 2018 by Jessica Dzubak, BSN, RN. The authors and planning committee members have declared no conflict of interest.
Disclaimer: Information in this study is intended for educational purposes only. It is not intended to provide legal and/or medical advice or to be a comprehensive compendium of evidence-based practice. For specific implementation information, please contact an appropriate professional, organization, legal source, or facility policy.
STUDY
Have you ever shared your personal problems with a patient (or client)? Given a patient a gift? Complained to a patient about a co-worker? Socialized, in person or via some form of social media, with a patient outside of your professional capacity? Accepted a gift of more than minimal value from a patient or family member? If you answered yes to any of these questions you may have crossed a professional boundary. Crossing a professional boundary is a violation of the Ohio Nurse Practice Act (Ohio Revised Code [ORC] Section 4723.28 [B.31], 2015b), and the rules adopted by the Ohio Board of Nursing (OBN) Ohio Administrative Code (OAC) 4723-4-06 (2015). While most nurses recognize that engaging in sexual misconduct with a patient is wrong both legally and ethically–what actually constitutes that “misconduct” is often difficult to define. For example, many nurses ask, “Isn¹t it all right to date a former patient?” The relationship between boundary crossings and sexual misconduct is often poorly understood.
Maintaining professional boundaries and avoiding inappropriate sexual involvement can pose dilemmas for nurses who frequently find themselves sharing in their patient’s most intimate life events. The very essence of nursing can be a “slippery slope” for many well-intentioned but naive, uninformed nurses. Patients trust that nurses will work in the patients’ best interest. When a nurse engages in a sexual relationship with a patient, or otherwise crosses a professional boundary, the nurse-patient relationship is being abused (National Council of State Boards of Nursing [NCSBN], 2018).
The purpose of this independent study is to make nurses more aware of and sensitive to the importance of maintaining a professional nurse/patient relationship and to identify some of the negative consequences that can occur, both for the nurse and for the patient, when these boundaries are crossed.
The OBN reported a relatively consistent number of complaints it received alleging sexual misconduct or boundary violations by its licensees between 2014 and 2016. But even at that, the numbers were not large with only 36, 45 and 25 cases reported in 2014, 2015, and 2016 respectively. (OBN, 2014, 2015, 2016). This increase was likely the result of the changing face of the health care delivery system. Nursing care that previously would have been provided in an acute care setting now is being provided in patients’ homes or community settings. Such settings are less public and less supervised than the traditional health care setting such as a hospital or nursing home. Working with patients where they live often results in less formality and a loosening of the restraint that typically characterized the nurse/patient relationship in an acute care environment.
Sexual Misconduct: What is it?
Sexual misconduct is about power. It is an extreme abuse of the nurse/patient relationship. It is exploitation. It is about impairment and irresponsibility (NCSBN, 2009) Engaging in sexual activity with a patient, as well as conduct that could reasonably be interpreted as sexual, is explicitly recognized as a violation of acceptable standards of safe nursing practice in Ohio (OAC, 2015). Behavior, including verbal behavior, which is sexually demeaning, harassing, or seductive, is considered sexual misconduct by the OBN. Under Ohio law, a patient is always presumed incapable of giving free, full, or informed consent to these behaviors (OAC, 2015).
In other words, the rules of the OBN clearly make the nurse responsible for assuring that sexual misconduct does not occur even with a seemingly willing patient. If the client consents, even if the client initiated the sexual contact, it is still considered sexual misconduct because it is an exploitation of the nurse/patient relationship (NCSBN, 2018).
The impact of sexual misconduct varies and can be complicated by the trauma of a failed personal relationship. Should sexual involvement cease, a patient’s response may range from a sense of exploitation to embarrassment, humiliation, and ultimately severe depression. None of these reactions is conducive to the health and well-being of the patient, which ought to be the underlying goal of all nursing interventions (NCSBN, 2018). Patients are not the only ones affected by sexual misconduct and/or harassment in the workplace. Evans (2018) states, “sexual harassment in healthcare can adversely affect employee health and, by extension, patient safety” (Evans, 2018, para. 5). Additionally, he states, “We have empirical data that shows a direct link between disruptive behaviors and sexual harassment to adverse patient outcomes, medication errors, and so on,” (Evans, 2018, para. 7).
What about dating a “former” patient?
Personal relationships that begin after the nurse is no longer caring for the patient pose significant questions. The NCSBN (2009) published guidelines for use by the various state boards of nursing that state, “A health care provider shall not engage, or attempt to engage, in the activities … with a former patient, client or key party within two years after the provider-patient/client relationship ends” (p. 6). The American Nurses Association (ANA) (2015) Code of Ethics does not specifically address post-termination relationships but clearly states any relationship with a current patient is prohibited. The rules of the OBN are also silent on this matter. In the absence of clear standards regarding post-termination relationships, in dealing with a case involving a post-termination situation, the Board of Nursing members would likely look to standards developed by other entities, such as the NCSBN to determine if the nurse’s conduct violated the laws and rules regulating professional practice. They would consider the type of nursing care provided and the length and nature of that care to determine whether sexual misconduct occurred. Regardless of when a personal relationship is established with a former patient, the nurse/patient role must not be resumed should future ongoing health care needs arise (NCSBN, 2009).
What are professional boundaries and why are they important?
Simply put, “professional boundaries are the spaces between the nurse’s power and the patient’s vulnerability” (NCSBN, 2018, p. 4). Valente (2017) defines boundaries as, “… the mutually understood physical, emotional, sexual, and social limits of a relationship”(Valente, 2017, para. 1). These boundaries are not visible. Nonetheless they define the types of behaviors that are most likely to enable nurses to effectively meet the health care needs of their patients and their patients’ families. The concept that there are “limits” to acceptable nursing behaviors within the nurse/patient relationship and the reason for those limits form the framework for an understanding of the intricacies of professional boundaries. Once the boundary is crossed, it may ruin the professional nurse-patient relationship completely (Petosa, 2018).
The NCSBN emphasizes that professional boundaries are necessary for an effective nurse-patient relationship. The NSCBN states, “the therapeutic nurse–patient relationship protects the patient’s dignity, autonomy and privacy” (NCSBN, 2018, p. 4). Nurses must keep patient’s dignity, autonomy and privacy in mind at all times in order to ensure boundaries are not crossed and trust is not violated.
Certain actions are not acceptable when a nurse is caring for a patient. Limits exist to help assure that a vulnerable patient is not exploited in any way even by a well-meaning nurse. “The power of the nurse comes from the nurse’s professional position and access to sensitive personal information” (NCSBN, 2018, p. 4). Nurses’ professional position affords them control over life-sustaining therapies and complex equipment through which they exert subtle but tremendous influence over their patients’ behaviors. This power, which is an essential element in the nurse/patient relationship, enables the nurse to positively influence the patient’s health status. However, “if the extent of that power is not limited through the establishment of appropriate professional boundaries, the patient is subjected to unacceptable risks that could ultimately affect the patient’s physical and emotional health” (OBN, 2002).
The difficulty in defining and maintaining professional boundaries has long been recognized within the nursing profession. The lines can easily be blurred, especially in long-term home care settings (Petosa, 2018). It can be even more difficult to maintain professional boundaries in pediatric home care settings, as “parents of pediatric patients and the children themselves can grow to view the nurse as a friend rather than a professional care provider” (Petosa, 2018, para. 2).
Case Study:
Nurse Anne has been Patient Tom’s home health nurse for 6 weeks following his surgery. Throughout this time, Anne and Tom have formed a trusting relationship. On the last day of Tom’s home health care, he takes a photo of himself standing to post on his Facebook, celebrating that he is officially “up and about” and near the end of his recovery. Tom posts some details about his surgery in this post.
Anne and Tom’s nurse-patient relationship ends at the termination of his care. Anne happens to be neighbors with someone who knows Tom, so she notices Tom appear in her “suggested friends” on Facebook. She clicks on Tom’s profile, and sees his proud post and feels good about her role in his recovery. Anne sees that Tom’s profile is “Public”, so she decides to “share” his post on her Facebook page. She adds to the post that Tom was unable to even stand up the first few weeks after surgery and has had a long battle with his disease. Because Tom posted these details about his own personal life and healthcare, Anne believes it is safe to continue sharing.
What are your thoughts? Is Anne correct in her thinking?
No. Green (2017) states, “patients are able to disclose their own information online; however a duty of confidentiality arises when a patient/client discloses information to a health professional in circumstances where it is reasonable to expect that the information will be held in confidence” (Green, 2017, para. 10).
Even if Anne had not added any details to her post, it would still not be considered appropriate and a violation of the nurse-patient relationship.
One study notes the lack of research on terminating the nurse-patient relationship (Ashton, 2016). Because of the intimacy of the nurse-patient relationship, especially over a long period of time, severing these relationships can prove to be difficult for both parties. This can become even more complicated with the addition of social media (Ashton, 2016). Severing ties with a former patient and their family does not mean you no longer care about them, but it is maintaining the professional and ethical boundaries of nursing practice. The nurse-patient relationship was still “real” and deeply meaningful (Ashton, 2016).
Boundary Crossings v. Boundary Violations
Boundary crossings:
“…are brief excursions across professional lines of behavior that may be inadvertent, thoughtless or even purposeful, while attempting to meet a special therapeutic need of the patient. Boundary crossings can result in a return to established boundaries, but should be evaluated by the nurse for potential patient consequences and implications. Repeated boundary crossings should be avoided” (NCSBN, 2018, p. 4).
Boundary violations:
“…can result when there is confusion between the needs of the nurse and those of the patient. Such violations are characterized by excessive personal disclosure by the nurse, secrecy or even a reversal of roles. Boundary violations can cause distress for the patient, which may not be recognized or felt by the patient until harmful consequences occur” (NCSBN, 2018, p.4)
What does the law say about maintaining professional boundaries?
Ohio law authorizes the Board of Nursing to take disciplinary action when a nurse fails to establish and maintain professional boundaries with a patient (ORC, 2015b). Nurses also risk disciplinary action if they obtain or attempt to obtain money or anything of value by intentional misrepresentation or material deception in the course of practice (ORC, 2015a). Rules of the OBN further define expectations with respect to boundary violations.
* Nurses are not to misappropriate a patient’s property or engage in behavior to seek or obtain personal gain at the patient’s expense.
* Nurses are not to engage in behavior that constitutes inappropriate involvement in a patient’s personal relationships or financial matters.
* Nurses are not to engage in any behavior that could reasonably be interpreted as inappropriate involvement (OAC, 2015).
Identifying Boundary Infringement
Excessive Self-Disclosure: The nurse discusses personal problems, feelings of sexual attraction or aspects of his or her intimate life with the patient.
Secretive Behavior: The nurse keeps secrets with the patient and/or becomes guarded or defensive when someone questions their interaction.
“Super Nurse” Behavior: The nurse believes that he or she is immune from fostering a nontherapeutic relationship and that only he or she understands and can meet the patient’s needs.
Singled-Out Patient Treatment or Patient Attention to the Nurse: The nurse spends inappropriate amounts of time with a particular patient, visits the patient when off-duty or trades assignments to be with the patient.
This form of treatment may also be reversed, with the patient paying special attention to the nurse, e.g., giving gifts to the nurse. If a nurse is receiving this type of attention from a patient, it is advisable for the nurse to seek the guidance of his or her supervisor.
Selective Communication: The nurse fails to explain actions and aspects of care, reports only some aspects of the patient’s behavior or gives double messages. In the reverse, the patient returns repeatedly to the nurse because other staff members are too busy.
Flirtations: The nurse communicates in a flirtatious manner, perhaps employing sexual innuendo, off-color jokes or offensive language.
“You and Me Against the World” Behavior: The nurse views the patient in a protective manner, tends not to accept the patient as merely a patient or sides with the patient’s position regardless of the situation.
Failure to Protect Patient: If the nurse fails to recognize feelings of sexual attraction to the patient, consult with a supervisor or colleague, or transfer care of the patient when needed to support boundaries (NCSBN, 2018).
Summary
Nurses often need help understanding how to effectively balance professionalism with effective care-giving. In other words: how to stay within the “zone of patient-centered care.” Administrators and managers as well as nursing colleagues can help nurses with this difficult matter by being sensitive to the challenges and alert to signs of boundary crossings.
Nurses must be aware of the reporting requirements and grounds for discipline on their license by the OBN. Nurses must be aware of and practice within the law and rules, but also the standards of care for the patient in whatever setting the nurse is working. “Nurses also need to be cognizant of the boundary violations that occur when using social media to discuss patients, their family or their treatment” (NCSBN, 2018, p. 10). Awareness is the key to avoiding crossing the professional boundary. Being cognizant of one’s own feelings and behaviors and observant of the behaviors of other nurses are important steps in finding the middle ground on the professional continuum. Nurses must also be clear about their own needs and the needs of their patients. They need to separate the personal from the professional. Patients need professional health care from a nurse, not personal friendship.
References
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Retrieved September 18, 2018 https://www.nursingworld.org/coe-view-only
Ashton, K. (2016). Teaching nursing students about terminating professional relationships, boundaries, and social media. Nurse Education Today, 37, 170-172. https://doi.org/https://doi.org/10.1016/j.nedt.2015.11.007
Evans, G. (2018). #MeToo in medicine? Sexual harassment in healthcare. Hospital Employee Health, 37(3). Retrieved from https://search-proquest-com.library.capella.edu/docview/2000994175?pq-origsite=summon
Green, J. (2017). Nurses’ online behaviour: lessons for the nursing profession. Contemporary Nurse: a Journal for the Australian Nursing Profession, 53(3). https://doi.org/10.1080/10376178.2017.1281749
National Council of State Boards of Nursing. (2018). A nurse’s guide to professional boundaries. Retrieved from https://www.ncsbn.org/ProfessionalBoundaries_Complete.pdf
National Council of State Boards of Nursing [NCSBN] Discipline Resources Committee. (2009). Practical guidelines for boards of nursing on sexual misconduct cases. Chicago, Illinois, USA: National Council of State Boards of Nursing. Retrieved September 18, 2018, from https://ncsbn.org/Sexual_Misconduct_Book_web.pdf.
Ohio Administrative Code (OAC). (2015). OAC 4723-4-06 Standards of nursing practice promoting patient safety. Retrieved September 18, 2018, from http://codes.ohio.gov/oac/4723-4-06v1.
Ohio Revised Code (ORC). (2015a). ORC 4723.28 Disciplinary actions (B)13. Retrieved September 18, 2018. from http://codes.ohio.gov/orc/4723.
Ohio Revised Code (ORC). (2015b). ORC 4723.28 Disciplinary actions (B)31. Retrieved September 18, 2018. from http://codes.ohio.gov/orc/4723.
Ohio State Board of Nursing (OBN). (2014). Ohio board of nursing annual report: SFY 2014. Retrieved from http://www.nursing.ohio.gov/PDFS/AnnualReport/FY14_Annual_Report_Final.pdf.
Ohio State Board of Nursing (OBN). (2015). Ohio board of nursing annual report: SFY 2015. Retrieved from http://www.nursing.ohio.gov/PDFS/AnnualReport/FY15_Annual_Report_Final.pdf.
Ohio State Board of Nursing (OBN). (2016). Ohio board of nursing annual report: SFY 2016. Retrieved from http://www.nursing.ohio.gov/PDFS/AnnualReport/AnnualReport2016.pdf.
Ohio State Board of Nursing (OBN). (2002). Disciplinary action. Nursing Momentum, 1(1).
Petosa, S. D. (2018). Maintaining professional nursing boundaries in the pediatric home care setting. Home Healthcare Now, 36(3), 154-158. https://doi.org/10.1097/NHH.0000000000000649
Valente, S. (2017). Managing professional and nurse-patient relationship boundaries in mental health. Journal of Psychosocial Nursing & Mental Health Services, 55(1), 45-51. https://doi.org/10.3928/02793695-20170119-09