When the nurse manager heard through the unit grapevine that Lauren was visiting Mike during her days off, she called Lauren into her office and asked her about her feelings toward her patient. Lauren admitted that she was sexually attracted to Mike and that they had talked about dating when he was discharged from the hospital. The nurse manager decided it would be best for Mike, the unit staff, and Lauren if Lauren was temporarily transferred to another ward. Had this intervention not taken place, the situation may have escalated into a nurse-patient boundary violation.

Although many RNs may be able to relay a similar story of personal impropriety in the workplace, there have been, in fact, few disciplinary cases related to violations of nurse-patient boundaries reported to the National Council of State Boards of Nursing, Inc’s. (NCSBN) national database in the last five years, says Vickie R. Sheets, RN, JD, director of practice and accountability. Based on the available information, boundary violations account for less than 1% of all licensure disciplinary actions taken against nurses, with less than 2% of that small number involving sex with a client. These numbers are small, and they represent cases reported to a voluntary databank that were specifically coded as boundary violations.

There may be additional cases coded differently, for example, as unethical behavior or unprofessional conduct. The numbers also do not reflect cases not reported to boards of nursing, situations that may have been handled within a facility or agency.

Despite the low reported occurrence of nurse-patient boundary violations in 1996, the NCSBN convened a focus group to further examine the issue due to lack of information in the nursing literature and the seriousness of the behavior when it does occur. The focus group developed a portfolio of resources related to professional boundaries geared for a variety of audiences, including nursing faculty, nursing employers, board members and staff, and even consumers. The NCSBN special services division developed a comprehensive training program called “Crossing the Line: When Professional Boundaries Are Violated.” The package includes a thought-provoking videotape depicting a scenario that illustrates the complexity of boundary situations, in addition to a speaker guide, transparency masters, and suggested learning activities.

Defining Sexual Boundaries

The boundaries of a nurse-patient relationship are the limits within the relationship that maintain the connection between nurse and client at a level on which the client’s needs for the expertise of the nurse can be met. Not all boundary crossings by the nurse are inappropriate and not all are sexual in nature.

The intimate physical and emotional nature of nursing care and the privacy it usually requires provide a setting in which misconduct can easily spring. Nurses are in a position of power within the nurse-patient relationship because of their specialized skills, the access to private information about the patient, and because of the patient’s vulnerability. “It is the access to information and the power differential that is critical,” says Sheets, adding that the context of the situation is important.

On the continuum of professional behavior, the therapeutic relationship falls midway between under involvement and over involvement. In the middle is the zone of helpfulness, the zone where “the therapeutic relationship performs as it was intended by the original contract between the client and the nurse,” according to NCSBN’s guidelines. It is this zone that best benefits patients’ needs.

Although under involvement can have negative consequences because not enough is being done to meet the patient’s needs, so can over involvement. Over involvement, whether intentional or unintentional, is a breach in the helping contract between nurse and client. It often begins with a simple boundary being crossed, such as disclosing inappropriate personal information to the patient. But it can lead to a more serious boundary violation or to the extreme case of sexual misconduct.

The simple boundary crossing of self-disclosure by the nurse can be therapeutic, depending on the context of the situation. For example, a nurse who shares that she or he has had the same surgical procedure with which the patient is faced may help ease the patient’s preoperative anxiety. A quick farewell peck on the cheek given to a long- time patient who is finally being discharged may be an appropriate boundary crossing, whereas a long, passionate kiss is obviously inappropriate.

Although some boundary violators have mental health problems that predispose them to developing unhealthy personal and professional relationships, others may become involved because they lack work or life experience or may be coping with personal issues, such as the dissolution of a significant relationship.

Red Flags of Boundary Violations

Sexual misconduct can occur in any practice setting. Some areas, however, provide a fertile breeding ground for boundary violations because of extended or repetitive contact, minimal supervision, and maximum control by the nurse. Some of these specialties are rehabilitation, dialysis, home care, and anesthesia.

Red flags in therapeutic relationships include spending excessive amounts of time with a patient beyond that which is expected, demonstrating possessiveness of the patient, inappropriate self-disclosure by the nurse, and exchanging gifts outside of the therapeutic realm. Overt warnings include either party dressing differently, as if to impress someone, flirting, and acting secretive or defensive toward others in terms of the relationship.

“The majority of nurses aren’t setting out to do harm. They get caught up in the situation,” says Sheets.

The NCSBN’s goal is to prevent boundary violations through awareness so that nurses can recognize situations that might predispose them to boundary crossings. Nurses are human beings with normal sexual emotions and desires, as are patients. They need to be aware of their feelings when working with patients and should bow out of a relationship if feelings of attraction arise. The feelings should not be treated as taboo, but as danger signs.

Whereas it is never appropriate to discuss these feelings with the patient, sharing them with a trusted colleague may aid in understanding them. If a nurse suspects a colleague is on the verge of a boundary violation, she or he must take action. “When you start to see the warning signs, it is your obligation to consider the needs of the patient and bring it to somebody’s attention,” says Sheets. “If it is somebody who you are close to, try to raise her or his awareness of the situation and the perceptions of others regarding the relationship. If you are not comfortable, don’t use that as an excuse to ignore the situation. Instead, talk to a more experienced nurse or a supervisor.”

Fallout from Boundary Violations

When violations do occur, a variety of consequences result. In addition to the harmful effects to the patient and impact on the image of the profession, the nurse violator is faced with disciplinary action from the employer and state boards of nursing. There is also the potential for legal action in states where sexual activity with a patient is considered a criminal offense.

Although the method by which sexual misconduct cases are handled varies from state to state, there are commonalities throughout. All nurses are entitled to due process or notification of the problem, in addition to an opportunity for a fair hearing, in which they can tell their side of the story in the presence of an objective person. There is also the opportunity for appeal.

Some states have alternatives to discipline. In 1983, Florida legislated the Intervention Project for Nurses (IPN), which is the oldest such program in the country. “Our mission is to protect the public from potentially unsafe practices and the rehabilitation and retention of good nurses,” explains Linda L. Smith, ARNP, executive director. Although these diversion programs are preferable to disciplinary action against the license of the nurse, Smith reports that the program has strict criteria and high expectations of participants. “The participant must receive appropriate, ongoing treatment and work in a nonpatient care-based setting,” says Smith. “Their immediate supervisor also gives ongoing feedback and reports.” The nurse in the IPN may even have to travel for treatment from an expert in the area of professional sexual misconduct. The statistics for the IPN are reflective of the national numbers for sexual misconduct. “We have had fewer than 10 cases in 15 years,” says Smith.

The issue of how to care for a patient who has been involved in a boundary violation after it is detected is an area that may benefit from more research and attention, says Sheets. “Expect to be tested by the patient and to deal with trust issues and anger. It may be difficult to get them to open up,” she says. The new nurse taking on the care of the patient needs to perform careful assessment, documentation, and teaching. “It is often the patient’s perceived breach of trust by the nurse that causes the most harm,” adds Sheets.

Self-awareness and recognition of any signals from the patient are vital in avoiding misconduct, in addition to basic components of nursing, such as respect for dignity, education related to procedures, and clear communication to establish boundaries. A good rule of thumb for boundaries mentioned in the NCSBN program is to “do or say nothing in private or public that cannot be documented in the client’s record.”

Thankfully, sexual boundary violations are not common among nurses, but ongoing self-surveillance and maintaining awareness that the potential exists for stepping over the therapeutic line of care are key to preventing the relationship from heading toward forbidden territory.