The relationship between a nurse and his or her client forms a core component of the nursing practice. Therefore, nurses are responsible for establishing and maintaining the relationship with their acquired nursing knowledge and skills ( Njine & Soroka , 2016) . They also are expected to apply caring behaviour and attitudes to ensure that the ongoing therapeutic nursing services result in the health and well-being of clients. In this regard, the nurse-client relationship ought to be based on respect, professional intimacy, trust and empathy ( Njine & Soroka , 2016; Hanna & Suplee , 2012; Peternelj ‐ Taylor & Yonge , 2003 ). It also necessitates nurses to use the power inherent in their provider's role. A therapeutic relationship is a goal-oriented, planned and contractual connection between a client and registered nurse that is aimed at providing care to a client in a bid to meet his or her therapeutic needs ( Peternelj ‐ Taylor & Yonge , 2003 ). This relationship takes place along a dynamic continuum whose goal is to ensure that registered nurses form a crucial component of the healthcare system. This paper is aimed at exploring the professional boundaries of registered nurses.
The Nurse-Client Relationships
Nurse-client relationships ought to be both professional and therapeutic. This implies that the relationship is purposeful and is aimed at advancing the best outcomes and interests for the particular client ( Njine & Soroka , 2016; Peternelj ‐ Taylor & Yonge , 2003 ). Further, the relationships ought to preserve the client’s autonomy, dignity and privacy. Establishment and maintenance of therapeutic relationships cannot be decoupled from the professional relationships between nurses and their clients. To ensure that a healthy professional relationship thrives, a nurse has to think about his or her actions, ask the most important questions and put nursing principles into practice. By establishing therapeutic relationships, registered nurses seek to gain an in-depth understanding of their clients' needs. Likewise, the goal is to create an environment that can foster effective, safe and ethical care. Lastly, a therapeutic relationship promotes the provision of competent and compassionate care.
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Five vital components define a therapeutic relationship between a client and a registered nurse. These include respect, fiduciary duty, trust, power and intimacy.
Respect: A therapeutic relationship has to the based on the respect for the client’s worth, dignity and rights. For instance, a registered nurse ought to acknowledge the unique personal experiences of their clients, and subsequently offer them the respect they deserve. Nurses validate a person’s intrinsic worth by relating and treating everyone with respect. They can also achieve this by establishing and maintaining appropriate boundaries with the aim of ensuring that the relationships are geared towards solely benefiting the client ( Hanna & Suplee , 2012 ).
Trust: In a nurse-client relationship, a client trusts that a registered nurse has the requisite abilities, knowledge and skills to offer competent, ethical, compassionate and safe care ( Njine & Soroka , 2016 ). The client also reckons that given the prevailing professional relationship, all the confidential information obtained will be protected by the nurse.
Empathy: The role of nurses in the nursing practice is to offer ethical and compassionate care. In pursuit of this, it is vital for nurses to portray empathy and understand the client's health care experience. A safe emotional distance is necessary for the nurse to remain professional and objective, in which case he or she can respond to the client's needs.
Power: A power imbalance characterizes a nurse-client therapeutic relationship. This is mainly due to the nurse's influence in the health care system, access to the client's private information, specialized knowledge, ability to influence decisions, and the fact that the client depends on him or her. Since the relationship is skewed in favor of the nurse, there is potential for power abuse ( Njine & Soroka , 2016 ). Thus, it is crucial for the nurse to remain conscious of the therapeutic relationship’s primary purpose so as to avert abuse.
Professional intimacy: This entails psychological, spiritual, physical and emotional aspects of the therapeutic relationship which result in a sense of closeness. Professional intimacy is also furthered by the disclosure of personal information by the client to the nurse. Owing to the inherence of professional intimacy in the nurse-client relationships, maintenance of professional boundaries is essential for any registered nurse.
Professional Standards and Boundaries for Registered Nurses
Standards coupled with indicators guide the therapeutic nurse-client relationship. Standards highlight the achievable and expected level of performance, against which a nurse's actual performance is compared. A standard is the minimum level of a nurse’s acceptable performance ( Njine & Soroka , 2016; College of Registered Nurses of British Columbia , 2008 ) . Thus, the nurses’ professional standards entail the levels of performance that are required of registered nurses in their professional practice. The standards reflect the nursing profession’s values, clarify the profession’s expectation of nurses, and are also the criteria against which employers measure the nursing practice, clients as well as nurses and their colleagues ( College of Registered Nurses of British Columbia , 2008 ). The indicators, on the other hand, are the specific factors that aid in meeting the professional standards. Thus, a nurse’s actual performance can be measured using the indicators. The professional standards of registered nurses include therapeutic communication, client-centred care, maintenance of professional boundaries, and protection of the client from abuse ( Njine & Soroka , 2016 ).
Professional boundaries are aimed at identifying the therapeutic relationship's parameters while taking cognizant of the fact that the relationship's purpose is to meet the therapeutic needs of the client. Thus, a registered nurse is expected to be accountable and to take responsibility for establishing and maintaining professional boundaries of therapeutic relationships irrespective of the client's requests and actions. In the process, it is crucial for the nurses to help clients understand when their actions or requests exceed the limits of the nurse-client relationship ( Njine & Soroka , 2016 ). The nurses also have to develop and follow a comprehensive care plan in collaboration with the client and the entire healthcare team so as to take care of all the client's needs. Any activity and approach that can be termed as a boundary crossing should be included in the care plan ( Hanna & Suplee , 2012 ). For instance, if a particular approach aids in offering care to the patient, it has to be part of the plan.
The nurses also have to recognize that in some practice settings there may be a need for increased vigilance on the maintenance of boundaries and professionalism. A good example, in this case, is the provision of care in a client's home. Since a nurse is likely to get involved in the client's private life, he or she has to be aware when his or her behavior is close to crossing the boundaries of a professional therapeutic relationship. The nurse also ought not to interfere with the personal relationships of his or her clients. Moreover, he or she should abstain from disclosing any personal information, except when that information meets the client’s therapeutic need ( Njine & Soroka , 2016 ). A client is likely to disclose information if doing so makes him, or her feel like his or her problems are being solved, or if such disclosure helps the nurse in administering care. A nurse has to continually clarify his or her role in the client-nurse relationship, particularly in cases where the limits and boundaries of the relationship become unclear to the client. A notable situation in this regard is a scenario where a nurse may be required to accompany a client to a family function so as to provide care therein.
The co-existing relationship between a nurse and a client should not undermine the objectivity and judgement in the therapeutic relationship ( Hanna & Suplee , 2012 ). For instance, if a nurse is providing care to a close or a family friend, he or she has to ensure that he or she does not compromise the nursing care in any way. A nurse should also abstain from being involved in financial transactions with the client's family if the dealings are not related to the provision of care ( Njine & Soroka , 2016 ). It is also crucial that a nurse consults with the manager or colleagues in cases where there is lack of clarity about whether a behavior may cross the therapeutic relationship’s boundary. This is particularly important in situations that warrant self-disclosure or exchange of gifts between the nurse and a client. A registered nurse should ensure that the nurse-client relationship and the resultant nursing strategies are developed with the sole aim of promoting the client's health and well-being, and not the nurse's needs. He or she should also document client-specific information about instances that necessitated consultation with a manager or colleague about an uncertain situation. In the context of maintaining boundaries, nurses have to consider the clients' cultural values even in cases that involve gift giving or self-disclosure.
Boundary Crossings and Violations
In some circumstances, a registered nurse may make a deliberate decision to diverge from the established professional boundaries. This crossing may be in a bid to meet the client’s therapeutic needs further. Therefore, boundary crossings are intentional and brief deviations in which a clear strategy of returning to the established limits exists ( Njine & Soroka , 2016; Peternelj ‐ Taylor & Yonge , 2003 ). Boundary violations, on the other hand, occur when a therapeutic relationship losses focus on the client's needs and are characterized by such attributes as secrecy and reversed roles. Hanna & Suplee (2012) argue that registered nurses have to be aware of the negative repercussions of crossing the professional boundaries on the clients. Notable violations include accepting gifts, self-disclosure, establishing a social relationship with a client and establishing a therapeutic relationship with friends, family members of acquaintances.
References
College of Registered Nurses of British Columbia. (2008). Professional Standards for Registered Nurses and Nurse Practitioners: Accountibility, Knowledge, Competence, Ethics, Service, Self-regulation . College of Registered Nurses of British Columbia.
Hanna, A. F., & Suplee, P. D. (2012). Don't cross the line: Respecting professional boundaries. Nursing2018 , 42 (9), 40-47.
Njine, D., & Soroka, B. (2016). Good quality interaction between the registered nurse and the patient: a systematic review.
Peternelj ‐ Taylor, C. A., & Yonge, O. (2003). Exploring Boundaries in the Nurse ‐ Client Relationship: Professional Roles and Responsibilities. Perspectives in Psychiatric Care , 39 (2), 55-66.
