Where does the boundary lie between personal and professional?

This past semester I completed my clinical placement on the Complex Continuing Care ward at Peterborough Regional Health Centre. Throughout this placement, I learned a lot about the chronic illness experience and especially about the importance of developing a therapeutic relationship while caring for patients in hospital. However, I had an experience that required me to examine the line between developing a therapeutic relationship and sharing personal information that may put the patient in an uncomfortable position.

One morning after I had completed my vitals and head-to-toe assessment for my own patient, the call bell rang. I answered it and asked how I could help, to which the patient replied “I was going to ask for a bedpan, but I think it’s too late…” – meaning I needed to gather supplies to clean up a bowel movement. Once I entered the patient’s room I realized the patient had been a caretaker at the high school I attended (as I grew up in Peterborough). I recognized him, but he had no idea who I was other than the nursing student who answered his call bell. I wanted to connect with my patient by telling him that I remembered him from several years ago, but I stopped myself – would this make him uncomfortable, considering I was about to clean up the result of the laxative he had been given earlier? Personally, if I were a patient who was about to be in a very vulnerable position, I would be uncomfortable knowing that the person who was performing my care had been a student at the school I worked at.

While this is a minor ethical issue (and one that may not have even been an issue) which pales in comparison to other cases of inappropriate nurse-patient interactions, it got me thinking about where that line between therapeutic and inappropriate exists. Professional boundaries are important in order to establish and maintain trust with a patient (National Council of State Boards of Nursing, 2016). Boundaries are also important for regulating your position of authority as a nurse. There exists a power imbalance between nurses and patients. Although we may do everything we can to see the patient as a partner in care, there is the unavoidable fact that we know more about the patient than they know about us, and this creates a power imbalance. Furthermore, while I remembered my patient from when I attended high school, he didn’t recognize me so this was one more thing I knew about him that he didn’t. To tell him that I knew him just before performing a task in which he is vulnerable could possibly be seen as an unnecessary use of this power imbalance.  

I turned to the literature to get more information on how nurses determine where this boundary lays. A paper by Gardner, McCutcheon, and Fedoruk (2015) discussed how these boundaries are not always black and white. The authors interviewed various health care providers to determine what is generally deemed appropriate or inappropriate. As expected, all participants deemed sexual relationships with current or past patients inappropriate. Interactions that were deemed “minor boundary crossings” included: receiving minor presents; calling a healthcare provider a “friend”; discussing your personal life with a patient or sharing personal views; or sharing anything about yourself that has no therapeutic value. Something that was seen as a minor boundary crossing by one participant but was a major boundary violation by another participant was giving out your personal phone number to a patient. Many of the boundaries that were seen as minor by some participants I certainly wouldn’t do in some contexts, but I may consider doing in other contexts. Furthermore, some actions may have therapeutic value for one patient but no therapeutic value for another. It is clear that determining where the boundary lies between therapeutic and inappropriate is not always easy.

Determining where this boundary lays can be even more difficult in rural communities. Corbett and Williams (2014) discuss this problem within the context of community nurses. They found that in rural communities where everyone knows each other it is difficult for the nurse to maintain professional boundaries. There is also the issue of protecting patient confidentiality of patients in the same community, which could inadvertently occur when these boundaries are so blurred. However, the researchers also found that sharing non-clinical information helped to build the patient’s trust in their nurse and allowed the two to establish common ground which strengthens the therapeutic relationship. Patients who are ill and unable to leave their homes often suffer from social isolation; sharing personal and social information helped the patient feel valued and improved their social connectedness and overall wellbeing (Corbett & Williams, 2014). This connects to my situation, because although Peterborough is not rural, it is a small enough community that the likelihood of caring for someone I know is quite high.

Finally, I consulted the Canadian Nurses Association (CNA) Code of Ethics for further information on this issue. There I found a guideline that I can relate to my situation: under Section D, “Honouring Dignity”, one of the ethical responsibilities states “Nurses respect the privacy of persons receiving care by providing care in a discreet manner and minimizing intrusions” (CNA, 2017). Telling my patient that I knew who he was before performing personal care and before the therapeutic relationship had been established could be considered intrusive – not physically intrusive, but emotionally intrusive. Again, determining boundaries is not black and white.

I ultimately decided to tell my patient that I remembered him from when I attended high school, but I told him this after I was done his care when we were just sitting and talking. At this point, the therapeutic relationship had been established and I had determined it was an appropriate time to tell him that I knew him. I certainly don’t think it would have been unprofessional or inappropriate to tell him before doing personal care, but it may have made him uncomfortable. As a novice nursing student I wanted to err on the side of caution. I believe the main takeaway from this experience is that boundaries in the nurse-patient relationship are contextual. Of course, there are certain boundaries, such as having a sexual or romantic relationship, which should never be crossed. However, for the most part boundaries should be determined by the environment of care, the patient’s personality and situation, and the type of care the patient is receiving. Christensen (2011) poses a questions that nurses should ask themselves when determining if an action or intervention is appropriate: “Will this intervention be of overall benefit to my patient, or does it satisfy some need in myself?” One of the reasons I went into nursing was the satisfaction I get from helping others, but I must acknowledge that the patient comes first. Every action that we take as nurses must protect the patient’s dignity and autonomy and if we are unsure then we should consult the Code of Ethics to make a decision.