TOPIC. The creation and maintenance of boundaries as they pertain to the nurse-client relationship.
PURPOSE. To challenge readers to reflect on their fiduciary responsibilities by identifying boundary crossings and violations.
SOURCES. Review of the literature and the authors' clinical and teaching experiences.
CONCLUSIONS. Although self-awareness and monitoring, debriefing, and availing oneself of supervision and education are important tools in creating and maintaining boundaries, in the final analysis, the nursing profession needs nurses who have the ability to make decisions about boundaries based on the best interests of the clients in their care.
Search terms: Treatment boundaries, boundary crossings, boundary violations, nurse-client relationship, fiduciary responsibilities
The ability to create and maintain treatment boundaries within the nurse-client relationship is one of the most important competencies required by psychiatricmental health nurses. However simple this declaration, in practice, boundary work is anything but straightforward. The familiarity and trust that develop between a nurse and a client, coupled with the seductive pull of helping, the complexity of the client's treatment needs, and a general lack of understanding of boundary theory, can threaten the integrity of the relationship and ultimately lead to boundary violations (Gallop, 1998b; McAliley, Lambert, Ashenberg, & Dull, 1996; Petemelj-Taylor, 1998; Pilette, Berck, & Achber, 1995; Schafer, 1997). Ironically, through engaging a client in a professional caring relationship--the essence of psychiatricmental health nursing--nurses are at risk of overstepping their professional boundaries. The clarity of this paradox is so strong that Collins (1989) and Simon (1999) have concluded that problems surrounding treatment boundaries are an occupational hazard experienced by all mental health professionals.
Contemporary psychiatric-mental health nurses practice in a multitude of settings and embrace a variety of therapeutic roles. They may find themselves working autonomously in independent practice or collaboratively as members of interdisciplinary teams. They may be employees of the healthcare system and practice in traditional community- and hospital-based settings, or they may find themselves working within the criminal justice system, in a variety of secure environments such as prisons and forensic psychiatric units. Although the issues dealt with in practice may on the surface appear to be quite significant, in reality a clearly defined distinction is nonexistent. It is the therapeutic nurse-client relationship that is the foundation of psychiatric-mental health nursing, one that unites psychiatric-mental health nurses regardless of the settings in which they practice (Goering, 1993; Peplau, 1952, 1992, 1997).
Nurses frequently work in situations where the boundaries of the nurse-client relationship are tested, either by their own actions or through the actions of their clients. Their response to these "tests" is a matter of professional integrity, and nurses, by virtue of the power inherent in their professional role, are expected to do the right thing, even when it is not always clear what "doing the right thing" might look like. Unfortunately, much of the contemporary nursing literature addressing therapeutic treatment boundaries is largely anecdotal (Armstrong, 1996; Norman, 2000; Stevens, 1998; Taylor, 1998), with very few in-depth inquiries and critical analyses evident (Gallop, 1998b; Lidstone, 2000; Peternelj-Taylor, 1998; Pilette et al., 1995; Schafer, 1997). In a quest for additional knowledge concerning the role of boundaries in therapeutic relationships, nursing has frequently turned for assistance to other mental health disciplines such as psychology, medicine, and social work (National Council of State Boards of Nursing [NCSBN], 1996). While this approach has augmented the profession's understanding of treatment boundaries in general, the dilemmas surrounding the management of treatment boundaries within the nurse-client relationship continue to reflect a critical contemporary practice issue, one that requires ongoing discourse. …