A Nurse’s Guide to
Professional
Boundaries

A nurse must
understand and apply
the following concepts
of professional
boundaries.

3
Y

ear after year, nursing tops national
polls of the most widely respected and
trusted professions. The results of these polls
reflect the special relationship and bond between
nurses and those under their care. Patients can
expect a nurse to act in their best interests and
to respect their dignity. This means that a nurse
abstains from attaining personal gain at the
patient’s expense and refrains from jeopardizing
the therapeutic nurse–patient relationship. In order
to maintain that trust and practice in a manner
consistent with professional standards, nurses
should be knowledgeable regarding professional
boundaries and work to establish and maintain
those boundaries.

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A therapeutic relationship is one that allows nurses to
apply their professional knowledge, skills, abilities and
experiences towards meeting the health needs of the
patient. This relationship is dynamic, goal-oriented and
patient- and family-centered because it is designed to meet
the needs of the patient and family. Regardless of the
context or length of interaction, the therapeutic nurse–patient
relationship protects the patient’s dignity, autonomy and
privacy and allows for the development of trust and respect.
Professional boundaries are the spaces between the
nurse’s power and the patient’s vulnerability. The power of
the nurse comes from the nurse’s professional position and
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.
Boundary crossings are brief excursions across
professional lines of behavior that may be inadvertent,
thoughtless or even purposeful, while attempting to meet
a special therapeutic need of the patient. Boundary cross-
ings can result in a return to established boundaries, but
should be evaluated by the nurse for potential adverse
patient consequences and implications. Repeated boundary
crossings should be avoided.
Boundary violations can result when there is confusion
between the needs of the nurse and those of the patient.
Such violations are characterized by excessive personal
disclosure by the nurse, secrecy or even a reversal of roles.
Boundary violations can cause distress for the patient, which
may not be recognized or felt by the patient until harmful
consequences occur.
A nurse’s use of social media is another way that
nurses can uninten­ tionally blur the lines between their
professional and personal lives. Making a comment via
social media, even if done on a nurse’s own time and in their
own home, regarding an incident or person in the scope of
their employment, may be a breach of patient confidentiality
or privacy, as well as a boundary violation.

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Every nurse–patient relationship can be conceptualized
on the continuum of professional behavior. Nurses can
use this graphic as a frame of reference to evaluate
their behavior and consider if they are acting within
the confines of the therapeutic relationship or if they
are underinvloved or overinvolved in their patients’ care.
Overinvolvement includes boundary crossings, boundary
violations and professional sexual mis­ conduct. Under
involvement includes patient abandonment, disinterest
and neglect, and can be detrimental to the patient and
the nurse. There are no definite lines separating the
therapeutic relationship from under involvement or
over­involvement; instead, it is a gradual transition.
This continuum provides a frame of reference to assist
nurses in evaluating their own and their colleagues’
professional–patient interactions. For a given situation,
the facts should be reviewed to determine whether or
not the nurse was aware that a boundary crossing
occurred and for what reason. The nurse should be
asked: What was the intent of the boundary crossing?
Was it for a therapeutic purpose? Was it in the patient’s
best interest? Did it optimize or detract from the nursing
care? Did the nurse consult with a supervisor or
colleague? Was the incident appropriately documented?
Professional sexual misconduct is an extreme form of
boundary violation and includes any behavior that is
seductive, sexually demeaning, harassing or reasonably
interpreted as sexual by the patient. Professional sexual
misconduct is an extremely serious, and criminal, violation.
A CONTINUUM OF PROFESSIONAL BEHAVIOR
UNDER-
INVOLVEMENT
OVER-
INVOLVEMENT
THERAPEUTIC
RELATIONSHIP
Every nurse–patient relationship can be plotted on the
continuum of professional behavior illustrated above.

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BOUNDARIES AND THE CONTINUUM OF
PROFESSIONAL NURSING BEHAVIOR
The nurse’s responsibility is to delineate and
maintain boundaries.
The nurse should work within the therapeutic relationship.
The nurse should examine any boundary crossing,
be aware of its potential implications and avoid
repeated crossings.
Variables such as the care setting, community influences,
patient needs and the nature of therapy affect the
delineation of boundaries.
Actions that overstep established boundaries to meet
the needs of the nurse are boundary violations.
The nurse should avoid situations where he or she has
a personal, professional or business relationship with
the patient.
Post-termination relationships are complex because the
patient may need additional services. It may be difficult
to determine when the nurse–patient relationship is
completely terminated.
Be careful about personal relationships with patients who
might continue to need nursing services (such as those
with mental health issues or oncology patients).

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Q&A
What if a nurse wants to date or even marry a former
patient? Is that considered sexual misconduct?
The key word here is former. The following are important
factors to consider when making this determination:
What is the length of time between the nurse–patient
relationship and dating?
What kind of therapy did the patient receive? Assisting
a patient with a short-term problem, such as a broken
limb, is different than providing long-term care for a
chronic condition.
What is the nature of the knowledge the nurse has had
access to and how will that affect the future relationship?
Will the patient need therapy in the future?
Is there risk to the patient?
What if a nurse lives in a small community?
Does this mean that he or she cannot provide
care for neighbors or friends?
The difference between a caring relationship and an
overinvolved relationship is sometimes difficult to discern.
A nursing professional living and working in a small, rural
or remote community will, out of necessity, have business
and social relationships with patients. In these instances,
it is extremely important for nurses to openly acknowledge
their dual relationship with patients and to emphasize when
they are performing in a professional capacity.
The nurse must ensure the patient’s care needs are primary.
When this is not possible, nurses should remove themselves
from the situation or request assistance from
a supervisor or colleague.
REGARDING PROFESSIONAL
BOUNDARIES AND
SEXUAL MISCONDUCT

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Do boundary violations always precede
sexual misconduct?
Boundary violations are extremely complex. Most are
ambiguous and difficult to evaluate. Boundary violations
may or may not lead to sexual misconduct. In some
cases, extreme sexual misconduct, such as assault or
rape, may be habitual behavior, while at other times it is
a crime of opportunity. Regardless of the motive, extreme
sexual misconduct is not only a boundary violation, it is
criminal behavior.
Does patient consent make a sexual relationship
acceptable?
If the patient consents, and even if the patient initiates
the sexual conduct, a sexual relationship is still considered
sexual misconduct for a health care professional. It is
an abuse of the nurse–patient relationship that puts the
nurse’s needs first. It is always the responsibility of a health
care professional to establish appropriate boundaries with
current and former patients.

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RED FLAG BEHAVIORS
Some behavioral indicators can alert nurses to potential
boundary issues for which there may be reasonable
explanations. However, nurses who display one or more
of the following behaviors should examine their patient
relationships for possible boundary crossings or violations.
Signs of inappropriate behavior can be subtle at first,
but early warning signs that should raise a “red flag”
can include:
Discussing intimate or personal issues with a patient
Engaging in behaviors that could reasonably be interpreted
as flirting
Keeping secrets with a patient or for a patient
Believing that you are the only one who truly understands
or can help the patient
Spending more time than is necessary with a
particular patient
Speaking poorly about colleagues or your employment
setting with the patient and/or family
Showing favoritism
Meeting a patient in settings besides those used to provide
direct patient care or when you are not at work
Patients can also demonstrate signs of overinvolvement
by asking questions about a particular nurse, or seeking
personal information. If this occurs, the nurse should request
assistance from a trusted colleague or a supervisor.
What should a nurse do if confronted with possible
boundary violations or sexual misconduct?
The nurse needs to be prepared to deal with violations
by any member of the health care team. Patient safety must
be the first priority. If a health care provider’s behavior is
ambiguous, or if the nurse is unsure of how to interpret a
situation, the nurse should consult with a trusted supervisor
or colleague. Incidents should be thoroughly documented
in a timely manner. Nurses should be familiar with reporting
requirements and the grounds for discipline in their
respective jurisdictions; they are expected to comply with
these legal and ethical mandates for reporting.

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What are some of the nursing practice implications of
professional boundaries?
Nurses need to practice in a manner consistent with
professional standards. Nurses should be knowledgeable
regarding professional boundaries and work to establish
and maintain those boundaries. Nurses should examine
any boundary-crossing behavior and seek assistance and
counsel from their colleagues and supervisors when
crossings occur. Nurses also need to be cognizant of the
boundary violations that occur when using social media
to discuss patients, their family or their treatment. These
issues are discussed in depth in NCSBN’s brochure
A Nurse’s Guide to the Use of Social Media. Other
resources about social media guidelines can be found
at ncsbn.org/boundaries.
NCSBN PROFESSIONAL BOUNDARIES
RESOURCES
NCSBN offers a variety of resources pertaining to
professional boundaries:
The “Professional Boundaries in Nursing” video, at
ncsbn.org/464.htm, helps explain the continuum of
professional behavior and the consequences of boundary
crossings, boundary violations and professional sexual
misconduct. Internal and external factors that contribute
to professional boundary issues, including social media,
are explored.
The “Professional Boundaries in Nursing” online course
was developed as a companion to the video. The cost
of the course is $30. Upon successful completion of the
course, 3.0 contact hours are available. The course is
approved by the Alabama Board of Nursing. Register
at learningext.com.
Other resources can be found at ncsbn.org/boundaries .

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THE NURSE’S CHALLENGE
Be aware.
Be cognizant of feelings and behavior.
Be observant of the behavior of other
professionals.
Always act in the best interest of the patient.

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08/18
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