CHAPTER 4
BOUNDARY MANAGEMENT
Jeffrey S. Jones
CHAPTER CONTENTS
Risk Factors for Unhealthy Nurse–Patient Boundaries
Strategies for Maintaining Boundaries
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Define boundaries
2. Identify tangible boundaries that can be established in an interpersonal relationship
3. Explain the intangible boundaries important in interpersonal relationships
4. Differentiate between a boundary crossing and a boundary violation
5. Identify risk factors for establishing unhealthy boundaries
6. Apply the concepts of boundary management when engaging in an interpersonal relationship
KEY TERMS
Boundaries
Boundary crossing
Boundary violation
Counter-transference
Transference
In the therapeutic relationship, a nurse must be careful not to be over- or under-involved. The nurse, as a professional, must gain the trust and respect of the patient by presenting himself or herself as genuine and empathic while maintaining therapeutic BOUNDARIES, which is the space between the nurse’s power and the patient’s vulnerability (National Council of State Boards of Nursing [NCSBN], 2014). All nurses, especially novice nurses and those new to psychiatric-mental health nursing, need to continually think about their practice in terms of boundaries and relationships as this area is important to the professional practice of psychiatric-mental health nursing. This chapter describes professional boundaries and discusses the importance of boundary management as an integral part of the interpersonal process between the nurse and the patient.
BOUNDARIES
The term boundary typically refers to the physical and psychological space that a person denotes as his or her own. An individual’s boundaries provide a separation for that person from another’s physical and psychological personal space. Thus, a person’s boundaries are unique to that person and reflect his- or her own self.
Boundaries may be physical or psychological. Privacy, physical proximity, touching, and sexual behavior are examples of physical boundaries. Feelings, choices, interests, and spirituality are examples of psychological boundaries. Each person delineates the limits of his or her own physical and psychological boundaries that are important. What may be a boundary for one person may or may not be a boundary for another individual.
Boundaries also can be classified as rigid, flexible, or enmeshed. A person with rigid boundaries is unwilling to consider alternative views or ways of doing things. The person refuses to accept new ideas or experiences and often remains distant, possibly withdrawing from others. A person with flexible boundaries is able to relinquish his or her boundaries when necessary. The person is open to allowing others who are viewed as safe to enter his or her space. A person with enmeshed boundaries experiences a blending or overlapping with another person’s boundaries. Thus, it is difficult to determine where that person’s boundaries begin and end. Often the boundaries are blurred so that there is no clear delineation of boundaries for each person. Often, individuals with enmeshed boundaries cannot identify feelings or beliefs as his or her own or different from the other person.
Boundaries may be physical or psychological, and can be classified as rigid, flexible, or enmeshed.
Establishment of Professional Boundaries
The first step in understanding professional boundaries between nurses and patients is to remember that there is an imbalance of power in the nurse–patient relationship. Patients, by nature of their illness, are dependent on nurses for some aspects of their care. In psychiatric-mental health nursing, the patient also is vulnerable due to the mental illness. This vulnerability is highly evident for patients who are psychotic, have problems with communication, or who have been involuntarily committed. In contrast, nurses are in a position of power based on their knowledge, experience, and status.
The nurse–patient relationship must remain professional because of this imbalance of power. The patient expects that a nurse will respect his or her dignity. Throughout the interpersonal relationship, the nurse must abstain from obtaining personal gain at the patient’s expense. The nurse also refrains from inappropriate involvement in the patient’s personal relationships.
The American Nurses Association (ANA) Code of Ethics for Nurses (Section 2.4) describes the nurse–patient relationship, addressing boundaries in this relationship: The work of nursing is inherently personal. Within their professional role, nurses recognize and maintain appropriate personal relationship boundaries (ANA, 2015).
Failure to maintain professional boundaries can result in a disciplinable offense by a state board of nursing or regulating body. Most states have language regarding the need to maintain professional boundaries in the nurse–patient relationship. In the United States, the National Council of State Boards of Nursing (NCSBN) has taken a strong position about failing to maintain professional boundaries and issued the following to facilitate disciplinary action at the local level:
Professional boundaries are the spaces between the nurse’s power and the patient’s vulnerability. The power of the nurse comes from the professional position and the 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. (NCSBN, 2014, p. 4)
Boundaries Within the Nurse–Patient Relationship
Applying Peplau’s or Travelbee’s theories about the nurse–patient relationship, boundaries are initially established during the orientation or original encounter phase and then maintained throughout the other phases. At any time during the relationship, new boundaries may be established or current boundaries may need to be adapted depending on the situation. However, regardless of the phase of the relationship, professional objectivity is essential to maintain boundaries. Without it, trust, the foundation of the interpersonal relationship, is destroyed. When boundaries are considered and attended to in a way of enhancing interpersonal relations, the process promotes health for the patient and growth for the nurse (Peplau, 1991).
Boundaries are initially established during the orientation or original encounter phase.
Recall that during Peplau’s first phase, orientation, and Travelbee’s original encounter, the nurse and patient are new to each other. Opinions may be formed about each other in the first few moments of meeting. This is the ideal time to begin establishing healthy boundaries within the relationship. The patient needs to know who the nurse is, why he or she is there, what the nurse can offer the patient, and what the patient can expect in return. Mutually agreed on goals can be introduced and discussed; these goals will be reviewed throughout the interpersonal relationship.
During the second phase, identification, the nurse identifies what he or she can now bring to the relationship to help the patient achieve the therapeutic goals. This phase allows the nurse to examine further opportunity for boundaries within the relationship. Potential issues of transference and counter-transference, if not apparent during the orientation phase, may emerge. TRANSFERENCE is a psychodynamic term used to describe the patient’s emotional response to the health care provider. In this case, the patient may feel and/or think that the nurse reminds him or her of a relative or a past romantic interest because there is some emotional or physical similarity to someone else in the patient’s life. The feelings generated may be either positive or negative. Likewise, the nurse may find that he or she is responding to the patient’s transference by developing COUNTER-TRANSFERENCE. Counter-transference occurs when the health care professional develops a positive or negative emotional response to the patient’s transference. For example, a nurse is assigned to care for an elderly woman who has been admitted with depression. This client is very seclusive but seems to gravitate toward the nurse. She perks up when the nurse is around and when she does come out of her room she asks for the nurse at the desk. The nurse later discovers that the patient has a daughter about the same age as the nurse. It is possible that the patient is responding to the nurse based on feelings about her daughter. The nurse, on the other hand, notices that she is becoming irritated and uncomfortable when around this patient. The more she seeks out the nurse, the more the nurse avoids the patient. Not only does the patient’s physical appearance remind the nurse of her recently deceased grandmother, the grandmother also suffered from bouts of depression toward the end of her life. The nurse may not have fully completed processing her grandmother’s death. This patient’s attraction to the nurse may be triggering personal feelings and thus interfering with the establishment of a therapeutic relationship. Being able to manage transference and counter-transference is very important in boundary management to maintain a professional interpersonal relationship and to deliver appropriate nursing care.
In the third phase, exploitation, the bulk of the work in the nurse–patient relationship is accomplished. Consider this example. A nurse is working with a young woman who has found herself chronically depressed and disillusioned about her ability to have long, sustained, healthy relationships with men. Within the interpersonal relationship, information was discovered that the young woman’s father abused alcohol and was physically and psychologically abusive to the mother. The young woman has stated that she never wanted to marry or be with a man like her father, yet she has continued to develop relationships with men who are very similar to her father. The nurse senses that the patient wants to develop insight and understanding of her own behavior. Subsequently, using skillful conversation, the nurse guides the patient toward awareness in recognizing that the young woman is simply following paths of least resistance, and entering into relationships that feel most comfortable to her. During moments of insight from the work in this phase, the nurse and the patient may feel a strong connection to each other. If not managed appropriately, boundaries could be violated. The patient may feel grateful that the nurse has helped her solve a particularly troubling dilemma. The nurse, in turn, feels a sense of deep reward in having skillfully done so. As a result, the relationship is vulnerable and at risk for becoming personal rather than remaining professional. During this time, the nurse must manage transference and counter-transference with the ever-present reminder that the power of the nurse comes from the professional position with access to private knowledge about the patient. The maintenance of boundaries allows the nurse to control this powerful differential and allows a safe interpersonal relationship to develop to meet the patient’s needs.
During resolution, the last phase, the nurse and patient review the work done and the goals accomplished. If no further goals are set and the identified needs have been met, then the relationship is terminated. Boundaries are maintained based on the understanding that the professional relationship will end. Resolution can be problematic for nurses who have obtained personal gain from a successful experience in the exploitation phase. They desire to continue and to prolong that feeling, and thus delay terminating the relationship even though the goals have been met and the therapeutic work is complete. Careful attention to whose needs are truly being met will help the nurse make the best decision during this phase of the relationship.
Maintaining boundaries during the last phase is best addressed by focusing on conversations that summarize what was accomplished in the relationship and the reinforcement of goals. In addition, other aspects of terminating the relationship can be difficult, particularly if the patient is so thankful that he or she wants to give gifts, exchange personal phone numbers, or initiate other strategies to prolong the ending of the relationship. The idea is for the nurse to manage the relationship and maintain boundaries in a manner that keeps the relationship within the area of the therapeutic relationship (Figure 4-1) until resolution (NCSBN, 2014).
Managing transference and countertransference are essential to boundary management.
BOUNDARY ISSUES
Issues related to boundaries of therapeutic relationships may occur at any time in the course of treatment. However, they are best dealt with at the outset of the therapeutic encounters. It may be helpful to think of boundaries as rules or expected behaviors that regulate healthy conduct in meetings between patients and nurses. Establishing boundaries takes on added significance in mental health work because symptoms experienced with some patients put them at risk. It is the responsibility of the nurse to set clear boundaries, both tangible and intangible, for the therapeutic relationship. Box 4-1 lists some examples of tangible and intangible boundaries.
In the therapeutic relationship, tangible boundaries typically are established and negotiated at the beginning of the relationship. Intangible boundaries also must be addressed because these are as important in the nurse–patient relationship as tangible boundaries are. For example, sexually explicit or vulgar language violates boundaries and should never be used. In addition, the nurse and patient need to mutually negotiate and agree on whether to use first or full names. This decision typically reflects the customs where the treatment takes place. Self-disclosure, a very powerful tool, must be done appropriately and only when its purpose is to model, educate, foster a therapeutic alliance, or validate a patient’s reality. Self-disclosure is never to be used to meet the nurse’s needs. Misuse or overuse of self-disclosure could lead to overinvolvement and a weakening of the professional relationship.
The nurse dresses appropriately, addresses patients by their proper names, and uses selfdisclosure appropriately to maintain intangible boundaries.
Figure 4-1 Therapeutic relationship area as seen alongside Peplau’s phases of the nurse–patient relationship.
Adapted from NCSBN (2014). A Nurse’s Guide to Professional Boundaries—A Continuum of Professional Behavior.
BOX 4-1: BOUNDARIES: EXAMPLES OF TANGIBLE AND INTANGIBLE
TANGIBLE BOUNDARIES:
• Time, place, frequency, and duration of meetings
• Guidelines that prohibit the exchange of gifts
• Guidelines regarding physical contact between the patient and the nurse
• Understanding that sexual contact is never permitted
INTANGIBLE BOUNDARIES:
• Setting kind yet firm limits with patients if boundary violations are attempted by the client
• Dressing professionally (suggestive, flamboyant, or seductive clothing may send mixed messages and is unacceptable)
• Using language that conveys caring and respect
• Using self-disclosure very discriminately
Boundary Testing
Sometimes boundaries in the relationship will be tested by a patient. Some examples of boundary-testing behaviors include: (a) attempting to initiate a social relationship; (b) attempting role reversal where the patient offers care to the nurse; (c) soliciting personal information about the nurse; and (d) violating the personal space of the nurse. The nurse is responsible for maintaining the structure of the therapeutic relationship by reinforcing the boundaries.
Not all therapeutic relationships run smoothly. Patients are dynamic human beings that experience a wide range of emotions and feelings such as fear, sadness, or frustration. Being the recipient of health care can leave one feeling helpless and vulnerable. Additionally, the stressors of dealing with an illness, physical or emotional, can lead to challenges in the therapeutic relationship. Therapeutic Interaction 4-1 provides an example of how to maintain boundaries when a patient tests them.
One of the biggest challenges to boundaries occurs when patients attempt to convert therapeutic relationships into social ones, thereby testing the boundaries of therapeutic encounters. At times in the therapeutic relationship, social exchanges are appropriate, for example, during recreation times. In these instances, the nurse may use the interaction to acquire information about the patient’s behaviors, his or her perception of self, and his or her ability to sustain a social relationship. An activity, such as playing pool, can be a therapeutic strategy to develop trust and rapport, thereby assisting in the progression through the identification phase of the relationship.
Testing behavior will challenge the nurse to remain focused and goal oriented. Careful self-assessment in such situations will enable the nurse to use what the patient is saying and doing to intervene therapeutically. When the relationship proceeds therapeutically and is successful, the patient and nurse will arrive at outcomes such as independence, spontaneity, mutual trust, self-awareness, honesty, responsibility, and acceptance of reality that allows both to achieve resolution. Adhering to the guidelines for professional boundaries will aid in maintaining and stabilizing the boundaries of the therapeutic interpersonal relationship.
