Maintaining appropriate boundaries with patients

1 August 2014

There’s a slippery slope between going the extra mile for a patient or their family and crossing the threshold into inappropriate behaviour. Nurse-turned-solicitor ROBIN KAY explores the boundaries of this tricky issue.

It is widely accepted that the therapeutic relationship between nurse and patient is central to the quality of care.

But it is also acknowledged there’s a risk that this relationship may become something more than is strictly required for the delivery of care.

Sadly, the New Zealand Health Practitioners Disciplinary Tribunal website, www.hpdt.org.nz,contains a significant number of complaints against clinicians, including nurses, of inappropriate relationships with their current or former patients or health consumers.

Guidance on professional boundaries

Nursing guidelines around the world recognise the possibility that a nurse may fail to maintain professional boundaries. The Nursing Council of New Zealand issued a Code of Conduct for Nurses in June 2012. This code contains a set of standards describing the conduct and behavior that nurses are expected to uphold. Principle 7 of the code focuses on the need to act with integrity to justify patients’ trust, which includes the following:

7.13 Maintain a professional boundary between yourself and the patient and their partner and family, and other people nominated by the patient to be involved in their care.

7.14 Do not engage in sexual or intimate behaviour or relationships with patients in your care or with those close to them.

In recognition of the importance of maintaining appropriate clinical boundaries, the Nursing Council issued further guidance in June 2012 with the release of its Guidelines: Professional Boundaries – a nurses’ guide to the importance of appropriate professional boundaries.

That guide clearly notes that a sexual relationship with a current patient or one of their family members is inappropriate. However, the guide is less clear when advising nurses about relationships with former patients and their families, just stating that such a relationship “may be inappropriate”. The use of the word may indicate that there are some circumstances when such a relationship is deemed inappropriate and others when it is not.

The guide does makes it clear that where the clinical relationship was a psychotherapeutic one (with the patient/consumer accessing mental health services or intellectual disability services) or the misuse of the information by the nurse could compromise the health of the former patient, a sexual or intimate relationship may never be appropriate.

Despite the Nursing Council’s very best efforts to offer guidance on this tricky topic, the guide acknowledges that: “It is not possible to provide guidance for every situation and nurses must develop and use their own professional and ethical judgment and seek the advice of colleagues and/or their professional organisation when issues arise in relationships with patients.”

The guide details a number of factors that impact on whether a relationship will be deemed to be inappropriate or not, and these are taken into consideration by the Health Practitioners Disciplinary Tribunal when it considers a complaint of this nature:

  • how long the clinical relationship lasted – for example a short-term intervention is very different from long-term care
  • the nature of that relationship and whether there was a power imbalance that the nurse may have used to commence an intimate or sexual relationship
  • the vulnerability of the patient at the time of the care relationship, and their current vulnerability
  • whether the nurse is exploiting information gained from the clinical relationship
  • whether the nurse may be caring for the patient or their family member in the future. 

An appearance before the tribunal, by its very nature, is not a pleasant experience and the best way to avoid this happening to you is to recognise the signs of becoming inappropriately involved with a patient or one of their family members (see over-involvement sidebar).

What should a nurse do if a person in their care or a family member is attracted to them?

Sometimes a nurse will find that a person that they are caring for, or their family member, is attracted to them and displays sexualised behaviour, perhaps flirting in the first instance. When this occurs, the nurse should firstly advise a colleague and consider contacting their professional body to seek advice on the most appropriate step to take.

The nurse may decide to speak with the patient or family member displaying the attraction, gently explaining what they have noticed and then outlining the professional boundaries that they as a nurse are required to maintain. This conversation is not an easy one for the nurse and the individual to have, and the individual should be reassured that the matter is being treated with the appropriate degree of confidentiality. However, despite the best efforts of the nurse, it may be that the result is that the clinical relationship cannot be re-established. In that case, the patient’s care should be transferred to another nurse.

What if a colleague is becoming over-involved?

Unfortunately, sometimes a nurse will not recognise that their relationship with a patient or a member of their family is becoming intimate. If you think that colleague is in danger of failing to keep appropriate professional boundaries, you have a duty to do something about it. If you witness such behaviour by a colleague, you cannot ignore it. Standard 6.9 of the Nurse’s Code of Conduct states that a nurse has a duty to:

“Intervene to stop unsafe, incompetent, unethical or unlawful practice. Discuss the issues with those involved. Report to an appropriate person at the earliest opportunity and take other actions necessary to safeguard patients.”

You may consider speaking to your colleague about what you have witnessed. If you decide to take this approach, remember that what you say may come as a total surprise to your colleague, so give some thought to when, where and how you raise this with them.

If you decide to speak to your colleague, you should explain:

  1. what you saw or heard
  2. what impact the act appeared to have on the patient or their family member (or on the nurse, if the nurse was the recipient of the words or acts)
  3. the need to maintain appropriate boundaries as per the Code of Conduct.

If you feel uncomfortable speaking to your colleague – or having spoken to your colleague, he or she fails to acknowledge the matter – you should speak to your supervisor. To ensure that you accurately recall the event you witnessed, and also to provide your supervisor with clear information, you should write down the details of the incident, including date, time, parties involved, and any other witnesses to the event. If you have approached the nurse, you should document the detail of this conversation. Taking this action protects the patient, the nurse and yourself.

Key points

A relationship with a current patient or a member of their family is deemed to be inappropriate.

A relationship with a former patient or member of their family may be inappropriate. While the Nursing Council guidelines and tribunal decisions do give an indication of the factors they consider, it is very difficult for a nurse to be certain that they can enter such a relationship without fear of a professional misconduct complaint being made against them. If the nurse gets this wrong, they run a very real risk that their registration could be cancelled or suspended.

If you are unclear about professional boundaries, consider discussing it with a colleague knowledgeable in this area, or attending an appropriate course, such as the one offered by the College of Nurses. It’s better to do this type of course out of choice than it being a stipulation by the Health Practitioners Disciplinary Tribunal of you getting your registration back.

You trained for years to get your nursing registration – don’t make an uninformed decision about relationship boundaries and thereby run the risk of having your professional bodies decide whether you can keep it. If it feels dodgy, it probably is!

The author: Robin Kay RMN, Dip. Health, LL.B (Hons) and LL.M (Health Law) was a mental health nurse for more than 20 years before becoming a Christchurch solicitor. He has a keen interest in the legal aspects of nursing practice, particularly professional conduct, and is an associate member of the College of Nurses Aotearoa. robin.kay@laneneave.co.nz

Signs of over-involvement

A nurse can be alert to the possibility that their professional boundaries, or those of a colleague, are being threatened by looking out for the following:

  • revealing information about their personal life that’s unnecessary in the context of care
  • the nurse attempts to see the patient, or the patient attempts to see the nurse, outside normal working hours
  • the nurse thinks about the patient when not at work
  • the nurse provides the patient with personal contact details
  • the nurse maintains contact with the patient after the clinical relationship has ended
  • the patient is only willing to speak with a particular nurse
  • the nurse changes their dress style for work when working with a particular patient
  • the nurse’s interactions with the patient appear flirtatious, or contain sexual references
  • the nurse fosters the patient’s reliance on them, rather than encouraging them to be more independent.

How to avoid over-involvement

  • Keep to relevant personal detail in history taking
  • Be aware of the messages, verbal and non-verbal, that the nurse sends to patients and that there is a risk that they may be misinterpreted
  • Refrain from undue familiarity
  • Offer the option of an appropriate chaperone during intimate examinations or treatment
  • Be cautious of the context and intent if accepting a gift from a person in your care
  • Never use sexually demeaning words or actions or dirty jokes
  • Maintain proper appointment systems
  • Be aware that people may be vulnerable at times of crisis in their personal life
  • Do not involve the people in your care or members of their immediate family, or any other person involved with their care, in your personal problems
  • Consult with colleagues about difficult situations.

CASE STUDY: Tribunal finds nurse’s relationship with stroke victim’s husband ‘wrongful’

Ms S suffered multiple strokes in November 2008 and was transferred into X Hospital in December 2008 where she was settled into the facility by Nurse E. Ms S was left with total right-sided hemiplegia, initially had no speech, is now mobile with an electric wheelchair but still requires assistance with all daily cares. Ms E’s role meant she was only occasionally involved in Ms S’s care but met Ms S’s husband Mr S and her family.

In June 2009, around six months after Ms S was admitted to the hospital, Ms E and Mr S met at a social function and an intimate relationship began to develop. Nurse E was aware that her developing relationship with Mr S might place her in a ‘conflict of interest’ and in July informed her manager Ms R and told her she didn’t want to leave the hospital but understood if she had to. Ms R said they discussed the fact that Mr S was under a “great deal of stress”, the need to inform Ms S’s family, and was given the impression from Nurse E that the relationship was ethically okay under Nursing Council guidelines. It was agreed that Nurse E should not provide patient care or plan care for Ms S.

The tribunal was told that news of the ongoing relationship split the hospital staff and by November 2009 rumours circulating in the local supermarket reached the DHB. This led to the redeployment of Nurse E in January 2010 and formal complaints being laid that she had breached the Nursing Council Code of Conduct. The Nursing Council professional conduct committee sent the complaint to be heard by the Health Practitioners Disciplinary Tribunal and recommended Nurse E be suspended for two years.

The tribunal found that Nurse E had entered into and continued an inappropriate relationship with Mr S between June 2009 and January 2010, which was an act of professional misconduct as it amounted to “malpractice in the scope of her nursing practice” and further that the relationship had brought, or was likely to bring, discredit to the nursing profession.

“It is wrongful conduct amounting to misconduct for a nurse to have a relationship of intimacy with the spouse or partner of a patient in circumstances such as this. It is for the nurse either to take the initiative to back away from the relationship or be prepared to compromise, if not completely abandon, his or her nursing career.”

The tribunal censured Nurse E and suspended her for six months but that suspension order was suspended for 12 months to allow Nurse E to demonstrate she understood the ethical standards required of her and under the condition that she had professional supervision for 12 months. She was also ordered to pay $21,000 towards the cost of the hearings.

NB The full decision can be read www.hpdt.org.nz/portals/0/nur10159pdecisionsubsweb.pdf