Baca (2011) listed five ways in which self-disclosure becomes problematic: (1) if the nurse’s problems or needs are disclosed; (2) if disclosure by the nurse becomes a common, rather than rare, event during interactions with a patient; (3) when the disclosure is unrelated to the patient’s problems or experiences; (4) if it takes more than a very short time during an interaction; and (5) the nurse discloses personal information even if it is clear that the patient is confused by the interaction. Becoming aware of one’s needs and making conscious efforts to have those needs met in one’s private life keep relationships with patients professional and therapeutic for the patient. When the nurse-patient relationship crosses professional boundaries, role confusion can result, risking harm to both patient and nurse.

Professional boundaries

Boundary issues are everywhere in nursing. They were first addressed by Florence Nightingale in the Nightingale Pledge (refer to Box 3-1 on p. 58 to review this statement). The American Nurses Association’s (ANA”s) Code of Ethics for Nurses (2001) also addressed boundaries. The subject of professional boundaries was detailed comprehensively by the National Council of State Boards of Nursing (NCSBN). The NCSBN defined professional boundaries as “the spaces between the nurse’s power and the client’s vulnerability. The power of the nurse comes from the professional position and the access to private knowledge about the client” (NCSBN, 1996, p. 1). Boundary violations occur when “there is confusion between the needs of the nurse and those of the client” (p. 2).

According to the NCSBN, nurse-patient relationships can be plotted on a continuum of professional behavior that ranges from underinvolvement (such as distancing, disinterest, neglect) through a zone of helpfulness (the ideal space) to overinvolvement (such as excessive personal disclosure by the nurse, secrecy, role reversal, touching, gestures, money or gifts, special attention, social contact, getting involved in a patient’s personal affairs, and/or sexual misconduct). Both underinvolvement and overinvolvement can be detrimental to patient and nurse (p. 3). A quick way of monitoring yourself with regard to boundaries is to ask yourself, “Can I tell a colleague about this?” If the answer is no, then you are at least on the edge of a boundary violation and need to take corrective measures. Secretive behavior is a signal that a nurse does not feel comfortable or is unwilling to share with trusted others (Baca, 2011). Box 9-2 describes a case in which a nurse was disciplined by his state board of nursing for failing to honor the professional boundaries between a nurse and patient.

BOX 9-2 NURSE’S RELATIONSHIP WITH PATIENT RESULTS IN DISCIPLINARY ACTION
Tapp v. Board of Registered Nursing, 2002 WL 31820206 P2d-CA

This case involved a California registered nurse at a psychiatric facility in Fresno who was accused of having sexual relations with his former patient after her discharge. The patient was hospitalized for emotional problems related to sex. She was hospitalized on a unit where the nurse worked the night shift. They became friendly; he brought her small gifts, gave her his telephone number, and called her during his off-work hours. After she was discharged, they spoke often by telephone, and he began to visit her at her apartment. On one occasion, the nurse gave her a tablet of a controlled substance.

One week after her discharge, they began a sexual relationship that lasted for 2 weeks. Shortly after the relationship ended, the patient was readmitted, “suffering adverse effects from the affair” (p. 4). The California Board of Registered Nursing initiated disciplinary proceedings for “acts of unprofessional conduct.” An administrative law judge heard testimony, made a determination of misconduct, and recommended that the nurse’s license be revoked, but stayed the revocation and recommended that the nurse be placed on probation for 5 years on multiple conditions. The California Board of Registered Nursing disagreed and ordered the revocation of his license. There were subsequent appeals, dismissals, and further appeals.

Nurses must realize that there can be no socialization between themselves and patients, particularly sexual in nature. Not only was this nurse’s behavior with this patient during her hospitalization “highly improper, but his socialization with the patient after her discharge from the hospital, not to mention the fact that he provided the patient with a controlled substance, was ample reason to impose strict disciplinary action” (p. 5).

Abstracted from Nurse’s relationship with patient results in disciplinary action, Nurs Law Regan Rep 43(8):4–5, 2003.

Failure to maintain professional boundaries with a patient is an offense reportable to your employer and/or your state board of nursing and violates nursing’s code of ethics. This means that nurses should have a thorough understanding of professional boundaries. Box 9-3 contains seven principles to guide nurses in determining professional boundaries across the continuum of professional behavior (NCBSN, 1996). You can find a .PDF file of the popular NCBSN publication explaining professional boundaries by following the links at www.ncsbn.org.

BOX 9-3 PRINCIPLES FOR DETERMINING PROFESSIONAL BOUNDARIES

1. The nurse, not the patient, is responsible for delineating and maintaining boundaries.

2. The nurse should work within the “zone of helpfulness,” which is neither aloof nor too intense/emotionally involved.

3. The nurse should examine any boundary crossing, be aware of its potential implications, and avoid repeated crossings.

4. Variables such as the care setting, community influences, client needs, and the nature of therapy affect the delineation of boundaries.

5. Actions that overstep established boundaries to meet the needs of the nurse are boundary violations.

6. The nurse should avoid dual relationships in which the nurse has a personal or business relationship with a patient, as well as the professional one.

7. Post-termination relationships are complex because the client may need additional services, and it may be difficult to determine when the nurse-client relationship is truly terminated.

Modified from National Council of State Boards of Nursing (NCSBN): Professional Boundaries: A Nurse’s Guide to the Importance of Appropriate Professional Boundaries, Chicago, 1996, National Council of State Boards of Nursing.

Reflective practice

Nurses care for a diverse array of patients whose values, beliefs, and lifestyles may challenge the nurses’ own values. Although nurses sometimes are attracted to patients, conversely, nurses may be repelled by some patients. Nurses who have emotional reactions to patients—positive or negative—sometimes feel guilty or disturbed about these feelings. Being self-aware means recognizing one’s feelings and understanding that, although feelings cannot be controlled, behaviors can. Effective nurses conducting themselves professionally take charge of their behavior to prevent their own prejudices, beliefs, and needs from intruding into nurse-patient relationships. This ability arises from self-awareness.

Developing self-awareness requires individuals to engage in personal reflection. This requires taking time to focus on their own thoughts, feelings, actions, and beliefs. Finding the time and space for reflective practice can be a challenge to busy students and practicing nurses alike. Reflection can produce discomfort as nurses become aware of the tensions and anxieties within themselves about their everyday activities. Nurses and nursing students may find that their personal values are challenged by the realities of practice. Importantly, nurses may recognize in themselves a desensitization to the needs of their patients because of time constraints, the need to create emotional space, or a personal dislike for a particular patient. It can be hard for you when you recognize that you may have thoughts that are less than kind about patients entrusted to your care. This makes the need for reflection more, not less, important. No human being is immune from emotional responses to others, both positive and negative. Despite the difficulty in coming to terms with your emotional responses to patients and to your work, becoming self-aware allows you to understand your responses and to look past your own negative (and positive) responses to particular patients in order to create and maintain a healthy professional space in which you can provide care most effectively. Box 9-4 contains a model for structured reflection that will be helpful to you reflecting on your practice and becoming more self-aware.

BOX 9-4 MODEL FOR STRUCTURED REFLECTION

• Write a description of an experience that seems significant in some way.

• What issue seemed significant to pay attention to?

• How was I feeling and what made me feel that way?

• What was I trying to achieve?

• Did I respond effectively and in tune with my values?

• What were the consequences of my actions on the patient, others, and myself?

• How were others feeling?

• What made them feel that way?

• What factors influenced the way I was feeling, thinking, or responding?

• What knowledge did or might have informed me?

• To what extent did I act for the best?

• How does this situation connect with previous experiences?

• How might I respond more effectively given this situation again?

• What would be the consequences of alternative actions for the patient, others, and myself?

• How do I now feel about this experience?

• Am I now more able to support myself and others as a consequence?

• Am I now more available to work with patients/families and staff to help them meet their needs?

Johns C: Guided Reflection: Advancing Practice, Oxford, 2002, Blackwell Science, p. 10. Reprinted with permission of Wiley-Blackwell.

Avoiding stereotypes

Stereotypes are simplistic, distorted images used to describe or characterize groups. Stereotypes result in prejudices and negative attitudes developed through social and cultural interactions. Even well-educated professionals have stereotypical views of groups of people different from themselves and may hold expectations of those groups based on these distorted images. Stereotypes are established through a lifetime of experiences and negatively affect relationships with people in the stereotyped group. Because stereotypes and prejudices tend to persist despite contrary experiences, they are irrational or illogical beliefs. Stereotypes may be based on ethnicity, gender, nationality, or political affiliation, among others; for instance, portrayals or descriptions of nurses as sex objects, physicians’ handmaidens, or not bright enough to attend medical school are all stereotypes that negatively affect the profession of nursing.

A subtle form of stereotyping that affects nursing is related to expectations of others based on one’s distorted view of the other. This in turn causes problems relating to patients who are stereotyped. For example, if a nurse expects that elderly people are irritable and demanding, the nurse may seek to avoid caring for elderly patients or to treat their complaints as unimportant: “just another grumpy old person.” Moreover, some nurses demonstrate lack of respect to elderly patients, using names like “sweetie,” “dear,” and “honey,” among others.

Professional nurses deliver high-quality care to all patients regardless of the patients’ ethnicity, age, gender, sexual orientation, religion, lifestyle, or diagnosis. The ANA’s Code of Ethics for Nurses (see inside back cover of this text) requires nurses to do this. Nurses are prone to stereotyping just like anyone else; however, the nature of the nurse-patient relationship requires that nurses become aware of how their stereotypical views of certain patients negatively affect the delivery of care. Every professional nurse’s goal is to accept all patients as individuals of dignity and worth who deserve the best nursing care possible.

Becoming nonjudgmental

Prejudices are simply what the word implies: judging a person in advance of knowing him or her, based on stereotypes and biases. Prejudices are strong and are often outside our awareness, which in turn makes acceptance of others difficult. Prejudging others as “good” or “bad,” “right” or “wrong,” is usually unconscious, hence the need for nurses to examine their prejudices and become aware of when prejudices are operating. Nonjudgmental acceptance means that nurses acknowledge all patients’ rights to be who they are and to express their uniqueness. Acceptance conveys neither approval nor disapproval of patients and their personal beliefs, habits, expressions of feelings, or lifestyles.

Therapeutic use of self begins with the ability to convey acceptance to patients and requires self-awareness and nonjudgmental attitudes on the part of nurses. Ongoing examination of attitudes toward others is both a lifelong process and an essential part of self-awareness, maturation, and personal growth.

Thinking differently about nurses and patients: Caring and human relatedness

The traditional nurse-patient relationship has been taught and practiced since the middle of the twentieth century; however, several assumptions on which it is based no longer hold true in many of today’s practice settings. For instance, this older model assumes that the development of the nurse-patient relationship is linear, is incremental, and requires trust-building in the earliest phases of the relationship, and importantly, it assumes that patients desire relationships with nurses, wish to receive services from them, and will cooperate and comply with those nurses (Hagerty and Patusky, 2003).

Although the traditional time-honored nurse-patient relationship is still appropriate in many settings, the assumptions on which it is based are being challenged by the reality that patients today are more acutely ill, nurses’ workloads have increased, and the time nurses spend with patients may be quite limited. This raises the question of how we can rethink the nurse-patient relationship and find ways to modify it to suit today’s contexts of health care delivery.

Patient-centered care

Patient-centered care has been proposed as an approach to alleviating some of the difficult problems that currently trouble the U.S. health care system, such as poor care quality, limited access to care, and dehumanization of care (Hobbs, 2009). In a detailed analysis, Hobbs found that alleviating vulnerabilities (e.g., feeling alienated, lack of control) experienced by the patient is central to patient-centered care in acute care settings. Furthermore, the process of therapeutic engagement is the key process in alleviating vulnerabilities, and one of the mechanisms by which this occurs is by the nurse’s caring presence (p. 55).

Theories of caring and human relatedness provide a powerful basis for practice. Many theorists have written about the nature of the nurse-patient relationship, with several writing about caring as the central concept in nursing, through which effective nursing practice occurs. Swanson (1991) defined caring as “a nurturing way of relating to a valued other, toward whom one feels a personal sense of commitment and responsibility” (p. 165). Five caring processes are germane to nursing practice: (1) knowing, (2) being with, (3) doing for, (4) enabling, and (5) maintaining belief (Swanson, 1991). Others have written about caring in nursing, including Watson (1988), whose theory is discussed in Chapter 13, and Roach and Maykut (2010), who described the essential elements of comportment central to professional caring.

Hagerty and Patusky (2003) proposed a theory of human relatedness through which to conceptualize the nurse-patient relationship. Each nurse-patient contact holds the potential for connection and goal achievement, as opposed to one step in a lengthy relationship-building process. They also recommended that nurses approach their patients with a sense of the patient’s autonomy, choice, and participation (p. 147), putting the relationship on a more equitable basis than the traditional nurse-patient relationship, which gives much of the power to the nurse.

Patient-centered care practiced by nurses whose central orientation to practice is caring and human relatedness provides a very strong foundation for effective intervention in today’s complicated and confusing health care environment. Communication is the primary instrument used by nurses and through which nursing care occurs. A basic understanding of communication theory is a necessary component of becoming a more effective communicator and, therefore, a better nurse.

Communication theory

Communication is the exchange of thoughts, ideas, or information and is at the heart of all relationships. Jurgen Ruesch (1972), a pioneer communications theorist, defined communication as “all the modes of behavior that one individual employs, conscious or unconscious, to affect another: not only the spoken and written word, but also gestures, body movements, somatic signals, and symbolism in the arts” (p. 16).

Communication begins the moment two people become aware of each other’s presence. Communication occurs when one is in the presence of another person, even if no words are spoken. Even when alone, people routinely engage in “self-talk,” which is an internal form of communication.

Levels of communication

Communication exists simultaneously on at least two levels: verbal and nonverbal. Verbal communication consists of all speech and represents the most obvious aspect of communication. Much of one’s message, however, consists of nonverbal communication. Nonverbal communication includes grooming, clothing, gestures, posture, facial expressions, eye contact, tone and volume of voice, and actions, among other things (Figure 9-1). Words can be used to mask feelings, but individuals are less able to exercise conscious control over nonverbal communication than verbal communication, therefore the nonverbal component may be a more reliable expression of feeling. Nurses must pay attention to nonverbal messages as closely as they do to verbal ones.

FIG 9-1 Nonverbal communication consists of grooming, clothing, gestures, posture, facial expressions, tone and volume of voice, and actions. Nonverbal communication is particularly important to patients using mechanical ventilation or whose ability to speak is otherwise impaired. (Photo used with permission from iStockPhoto.)

Consider this example: A nurse who is preparing a patient for a breast biopsy notices that the patient keeps her head turned away, has tears in her eyes, and will not look at the nurse. When the nurse says, “Is there anything you want to talk about or ask?” the patient responds, “No, I’m fine.” The sensitive nurse would pay closer attention to her nonverbal communication than to the spoken word. If the nurse pays attention only to the patient’s words, her underlying feelings would be ignored. The nurse’s job in evaluating this patient’s needs is made more difficult by the incongruence between her verbal and nonverbal messages.

When congruent communication occurs, the verbal and nonverbal aspects match and reinforce each other. In incongruent communication, the words and nonverbal communication do not match. Incongruent communication creates confusion in receivers, who are unsure which level of communication they should respond to. Nurses should be alert to incongruent communication for clues to patients’ unexpressed feelings. Nurses need to understand that patients are vulnerable, and expressions such as “I’m okay” or “No, I’m fine,” despite their incongruent nonverbal cues, do not mean that your patient is lying. It may simply mean that the patient is not ready or willing to share verbally what their nonverbal communication is relaying.

Elements of the communication process

Five major elements must be present for communication to occur: a sender, a message, a receiver, feedback, and a context (Ruesch, 1972). The sender is the person sending the message; the message is what is actually said plus accompanying nonverbal communication; the receiver is the person acquiring the message. A response to a message is termed feedback. The setting in which an interaction occurs—including the mood, relationship between sender and receiver, and other factors—is known as the context. All of these elements are necessary for communication to occur.

Consider the classroom situation. During a lecture, the professor is the sender, the lecture is the message, and students are the receivers. The professor (sender) receives feedback from the students (receivers) through their facial expressions, alertness, posture, attentiveness, and comments. The atmosphere in the classroom is the context. If the atmosphere is a relaxed one of give-and-take discussion between students and professor, the feedback is quite different from feedback in a more formal context of professor as lecturer and students as note takers. Figure 9-2 shows the relationships among the elements of communication.