Skip to main content Blog

Professional Boundaries: Crossing the Line Comes With Consequences


Professional boundaries are established for patients' protection, as well as staff.

A nurse manager is concerned about an unlicensed male staff member at a respite/crisis center for people with dual diagnoses of intellectual and developmental disabilities. The male worker is a Facebook friend with one of the female patients there. The female client has expressed a fondness for this staff member. The client's guardian was quite upset when she found out about the patient's fondness for the male staff member. The nurse manager wonders what she should do about this situation, as the staff member is in direct contact with all clients at the facility.

Defining professional boundaries

These boundaries have been defined by various professional healthcare associations and organizations. For example, the National Council of State Boards of Nursing has differentiated the therapeutic relationship of a nurse and patient from one that crosses over into boundary violations in its 2018 publication "A Nurse's Guide to Professional Boundaries". A therapeutic relationship, according to the NCSBN, respects a patient's dignity, autonomy and privacy and allows for the development of trust and respect.

Professional boundaries between a nurse and a patient respect the nurse's power and the patient's vulnerability. When boundary violations occur, confusion between the needs of the nurse and those of the patient occur.

The NCSBN and other organizations describe "a continuum of professional behavior" in which the therapeutic relationship is at the continuum's center with under-involvement at one end and over-involvement at the other. Either extreme of the continuum can result in harm to the patient. For example, over-involvement may result in keeping secrets with the patient or using social media to communicate with that person. Under-involvement may result in abuse or neglect of the patient. The NCSBN warns that an imbalance of the continuum is a gradual one. Professional boundaries have been defined for other healthcare workers, including licensed and unlicensed staff. One example is by Ausmed in its article, "Understanding Professional Boundaries." Defined as "rules and limits that prevent the lines between career and client from becoming blurred," they help keep the balance of the relationship in the therapeutic zone of the caregiver-patient continuum.

Nurse manager must intervene

The nurse manager is right to be concerned about the male staff member's conduct and apparent inability to understand the potential ramifications of his conduct with the female client at the facility.

The nurse manager pointed out this posting on social media occurred after the client expressed a liking for the staff member and after the guardian was upset about the client's affinity for him.

It is clear the male staff member has begun to extend a professional relationship into a personal one and is doing so while the professional relationship is ongoing. This nurse manager must intervene quickly to avoid any harm to the patient because of the clear imbalance in the therapeutic relationship, which is extremely essential to this particular patient's well-being. The first step the nurse manager can take is to speak confidentially to her supervisor and the facility's CNO. If the facility has a risk manager, he/she should be informed by way of an incident report. Once all are made aware of the problem, they would be in a good position to discuss the male staff member's conduct with him. Hopefully, they would then take appropriate action, which should include counseling him about the facility's policy prohibiting this kind of conduct and why it is inappropriate and disciplining him pursuant to its disciplinary policy. Moreover, he should be informed that if the relationship is pursued and becomes a sexual one, he may face criminal charges.

If the staff member disregards this advice and any additional behavior continues, whether with this patient or others, he would need to be terminated.

If he is terminated, the facility would need to send a report to the entity or organization through which he acquired certification, if any. Since he is not licensed, a report to a licensing board would not be possible. The patient's guardian also should be informed of the recent posting and the actions administration took with the staff member. He or she might have some effective ideas about how to help the patient, who may be understandably upset or feel hurt if the staff member is no longer working with her or no longer working at the facility.

Guideposts for your practice

Being a nurse manager is no easy undertaking. It requires stellar leadership and solid knowledge of how best to handle staff and provide safe care that protects patients. It also requires a clear commitment to the Nurses Code for Ethics and Interpretive Statements. Specifically, as this nurse manager identified, she must protect the best interest of a patient in jeopardy. As a nurse manager, you also must remember that you are accountable and responsible for your own nursing judgment and action. So not intervening in a situation such as this one would be a breach of your code of ethics. Such a breach might place you at risk for disciplinary action under your state nurse practice act and rules. In addition, if you do not intervene, not reporting unethical, illegal or unsafe practice might be another charge. You also could be charged with unprofessional conduct that could have a tendency to deceive, defraud or harm the public.

In short, a risk to a vulnerable patient that involves violating professional boundaries must be eradicated as soon as it is identified.

Take these courses on ethics:

Nursing Ethics, Part 2: The Language of Bioethics (1 contact hr) Ethical theory provides a framework within which nurses can assess the acceptability of actions and the morality of judgments. This program informs nurses about the key terms, theories and principles found in bioethics to help ensure ethically sound decisions in patient care. Nursing Ethics, Part 5: The Process of Ethical Decision Making (1 contact hr) The principle of well-being, or beneficence, doing good and preventing harm, obliges the nurse to promote the health and safety of patients in decisions made by and for them. The principle of equity, or justice, requires that patients be treated fairly and equally in the decision-making process. This module will further explore these principles and discuss methods of determining decision-making ability in borderline cases. Nursing Ethics, Part 6: No Easy Answers: Ethical Dilemmas in Bioethics (1 contact hr) This module defines the dilemmas and explains the arguments on different sides of three hot-button issues: physician-assisted suicide, organ transplantation and genetic testing.