Navigating professional boundaries: The use of the therapeutic self in rehabilitation nursing
Murray J Fisher
For referencing Fisher MJ. Navigating professional boundaries: The use of the therapeutic self in rehabilitation nursing. Journal of the Australasian Rehabilitation Nurses’ Association 2020; 23(1):2-3.
The NSW Nursing and Midwifery Council receives several notifications regarding nurses crossing professional boundaries that constitute as boundary violations. Recently, at Sydney University where I am employed, I taught a unit of study on law and ethics in healthcare to registered nurses where students were required to discuss the ethical principles that underpin professional boundaries. It was clear from the nurses’ responses that they had not previously considered nor understood what their legal and ethical responsibilities were in relation to maintaining professional boundaries. This made me think about the nature of rehabilitation practice and how rehabilitation nurses maintain professional boundaries in everyday practice.
In rehabilitation nursing, it is essential that nurses develop close nurse–patient therapeutic relationships so they can know and connect with the patient and promote active participation in rehabilitation (Baker, Pryor, & Fisher, 2019b). This work requires nurses to provide emotional care, supporting the emotional needs of vulnerable patients whilst they adjust to the biographical disruption caused by their injury or illness (Baker, Pryor, & Fisher, 2019a). The complexity and nature of rehabilitation nursing requires nurses to be highly attuned to the emotions of patients and provide psychosocial care as well as physical care and body work. A common practice of rehabilitation nurses is the use of self-disclosure, disclosing personal information about oneself in order to connect with the patient. However, disclosing personal information about oneself may be a boundary crossing, a brief excursion across the professional boundary, one that, if repeated, could be perceived as over-involvement with the patient and therefore a boundary violation.
A systematic literature review (Manfrin-Ledet, Porche, & Eymard, 2015) reported seven themes found from the non-research literature on boundary violations. These were: dual relations/role reversal; gifts and money; excessive self-disclosure; secretive behaviour; excessive attention/over-involvement; sexual behaviour; and social media (Manfrin-Ledet, Porche, & Eymard, 2015, p. 326). In a retrospective cohort study exploring disciplinary cases of boundary violations from the NSW Nurses and Midwives Tribunal and Professional Standards Committee between 1999 and 2006 (Chiarella & Adrian, 2014) a total of 29 boundary violation cases occurred, in which 14 registrants were subsequently removed from the register. The range of behaviours included “compliments, giving gifts, non-work-related communication (such as cards, letters and/or phone calls), inappropriate comments and disclosures and the use of self. The more serious issues were inappropriate touching (such as touching a patient’s breasts or vagina), showering patients (after mutual interest had been noted), hugging/cuddling, kissing or sex” (Chiarella & Adrian, 2014, p. 270).
Whilst nurses are educated regarding therapeutic self-disclosure, person-centred care, and the concept of partnering with patients, nurses are not necessarily aware of the power inequalities between the nurse and the patient. Nurses have access to patient clinical information when they enter a therapeutic relationship with the patient. Access to this information creates an inequality in power between the nurse and patient.
The Nursing and Midwifery Board of Australia (NMBA) defines professional boundaries as “limits which protect the space between the professional’s power and the client’s vulnerability; 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” (NMBA, 2010, p. 1). The NMBA Code of Conduct for Nurses (NMBA, 2018) clearly articulates the required conduct of nurses with regards to maintaining professional boundaries. This code requires nurses registered in Australia to: be aware of the power inequality between nurses and patients; manage the patients’ expectations and be clear about professional boundaries; avoid potential conflicts, risks and complexity of providing care for those whom the nurse may have a pre-existing personal relationship; avoid sexual relationships with current or previous patients whom the nurse had provided care; and recognise and report when over-involvement with a patient has occurred (NMBA, 2018).
The rehabilitation nurse must always balance the amount of self-disclosure and patient involvement to maximise the therapeutic relationship in order for the patient to optimise their rehabilitation outcomes without crossing the professional boundary. This is often complicated by the nature of our patients and the complexity of their needs. Rehab patients are often vulnerable, with a range of acquired disability and often requiring long-term rehabilitation and compensatory care. At all times, nurses must maintain the therapeutic relationship with patients, avoid boundary crossings, and prevent developing personal relationships with patients.
Murray J Fisher RN, DipAppSc (Nursing), BHSc (Nursing), MHPEd, ITU Cert, PhD
Baker, M., Pryor, J., & Fisher, M.J. (2019a). Nursing practice in inpatient rehabilitation: A narrative review (Part 1). Journal of Australasian Rehabilitation Nurses’ Association, 22(2):7–21.
Baker, M., Pryor, J. & Fisher, M.J. (2019) Nursing practice in inpatient rehabilitation: A narrative review (Part 2). Journal of Australasian Rehabilitation Nurses’ Association, 22(3): 7-15.
Chiarella, M., & Adrian, A. (2014). Boundary violations, gender and the nature of nursing work. Nursing Ethics, 21(3), 267–277.
Manfrin-Ledet, L., Porche, D.J., & Eymard, A.S. (2015). Professional boundary violations: A literature review. Home Healthcare Now, 33(6), 326–332.
Nursing and Midwifery Board of Australia (NMBA). (2010). A nurses guide to professional boundaries. https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards.aspx
Nursing and Midwifery Board of Australia (NMBA). (2018). Code of conduct for nurses. Retrieved from: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx