An important aspect of professionalism in nursing is the code of conduct, including boundaries of the professional role. In a world where technology such as social media is dissolving the barriers between public and private, boundaries may be difficult for new nurses to understand and enact. This article proposes the use of simulated scenarios as a way to help nursing students practice managing boundaries between professional versus personal relationships with patients and families.
Nurse-Patient Relationship Boundaries
The American Nurses Association’s Code of Ethics for Nurses is an excellent guide for orienting nursing students to appropriate boundaries in the nurse-patient relationship (ANA, 2001). Code of Ethics Provision 2.4 addresses boundaries, stating that nurse-patient relationships differ from “those that are purely personal and unstructured, such as friendship.” Boundaries are governed by the purpose of the nurse’s role, which is “preventing illness, alleviating suffering and protecting, promoting, and restoring the health of patients” (ANA, 2001). The statement explains that, although working closely with patients at vulnerable or stressful times may pose the risk of blurring appropriate boundaries, the nurse is responsible for maintaining professional boundaries at all times. For students, a boundary crossing could be explained as a situation in which the patient starts meeting the nurse’s needs, whether as egregious as romantic needs or as simple as the need to share a personal story, rather than the appropriate relationship of the nurse meeting the patient needs.
Cognitive load theory may be useful in understanding the importance of specifically addressing these types of issues outside of the clinical setting (Greene, et al., 2008). According to this theory, individuals can only attend to three to five units of information at any given time. For a student who, for instance, tends toward a highly emotional relational style, it may be difficult to make the conscious effort to maintain appropriate boundaries when the student also must focus on practicing skills, preparing medications, completing documentation, and other new tasks. Practicing in simulation can help the student recognize warning signs for when a relationship may stray into unprofessional territory. It can also help students develop and practice strategies for addressing potential boundary crossings in a gracious and professional, but firm, manner. Finally, simulation can help students problem-solve difficult relationships, including recognizing when they might need support from an instructor, supervisor, or colleague.
Case Study: Janey
To provide an example of how professional boundaries might be addressed in simulation, this article presents “Janey,” a fictional student with boundary difficulties. In her first clinical, Janey received a warning from the nursing program for an ethical violation. Janey was on a medical surgical floor working with a young, homeless single mother who was recovering from an appendectomy. Janey was moved by the woman’s difficult situation. She told the patient that her church offered services for women in her situation. Janey provided her personal phone number and e-mail to the patient and told the patient to contact her so that she could help connect her with these resources. When this situation came to the attention of the instructor, she spoke with the student. Janey said that she had felt a bit hesitant about giving her personal information, but the woman started crying while speaking about her situation, and Janey felt that she had to do something.
The school’s learning laboratory instructor, Brian, offered to work with the student to help develop insight on the issue. The learning lab had several relevant clinical scenarios. The learning objectives of the simulation activity for this student were as follows:
At the end of this lesson, the student will be able to
1. Describe appropriate nurse-patient boundaries and explain why the recent situation was a boundary crossing.
2. Recognize and describe situations in which she might feel tempted or pressured to behave in a way that crosses a professional boundary.
3. Apply strategies, such as therapeutic communication and planning of appropriate services, to appropriately help patients in difficult psychosocial situations.
To prepare for the simulation, Janey first met with the Brian. The objectives of the learning activity were described. Janey was assigned readings, including the ANA Code of Ethics, a chapter on “Professional Ethics and Boundaries” (DeWolf Bosek & Savage, 2007, pp. 77-79), and an article on professional boundaries (Sheets, 2000). On the day of the simulation, Janey first discussed the readings with Brian (CARNA, 2005). The instructor asked Janey what she learned from the readings and how she might respond differently. In working together, Janey was able to state specific verbal responses and actions such as responding to the patient with empathy, contacting social work to learn what services are available, and speaking with the patient’s nurse about considerations in discharge planning.
Next, the student completed a simulation with a teaching assistant (TA) playing the role of the patient. The scenario occurred in a simulation area that was set up as a hospital room to create the kind of conditions in which the student would face boundary challenges. The TA was in a gown, lying in bed with a simulated IV line. In this scenario, the TA played a young woman with cancer who was in an abusive relationship and seeking to leave the abuser. The scenario was similar, but not identical, to the situation that caused the student difficulty. As the TA cried and asked Janey, “what should I do?”, the student was able to practice the responses she had discussed with Brian such as:
Empathy: “It sounds like you’re in a really difficult situation. I’m sorry that things are so hard for you right now.”
Appropriate resources: “I know that there are resources for women in your situation. I’m going to speak with social work to see what is available for you.”
The student still used too much self disclosure (“My sister was in a similar relationship. It was hard for her to get out, but she’s doing really well now.”)
Janey, Brian, and the TA debriefed after the scenario. The student expressed that she felt much more prepared by having some rehearsed responses. The TA reflected that she felt reassured and valued by Janey. Janey recognized on her own that she had overstepped with the statement about her sister. With Brian’s guidance, she reflected on reasons for this (i.e., the need to provide reassurance to the point that the patient would stop crying). She left the scenario feeling more equipped to respond to boundary challenges and with awareness of situations in which she might be tempted to cross a boundary.
Implementing in a Group Setting
Janey’s scenario provides an example of a remedial simulation in which a boundary violation has already occurred. This approach could help get students back on the right track and develop confidence in dealing with difficult situations. However, simulation also could be used in a group setting to train students how to recognize and respond to boundary challenges (Schwartz, 2009). For instance, students might prepare for a simulation with readings and reflection as Janey did. They could brainstorm responses in small groups. They might participate in a simulation where one student acts as the nurse while the others observe, then debrief as a group what went well and what could have been done differently. Having different students address the same simulated situation would be a good way for students to learn responses other than those at which they might arrive on their own. Having the group practice on different scenarios could also be useful in having students apply similar skills across differing situations.
To summarize, it is important to offer students guidance on how to avoid blurring and crossing appropriate nurse-patient boundaries. As with any skill, protecting professional boundaries can be learned and practiced. Simulation is an ideal way to help student perform such practice and reflect on their own vulnerabilities and strengths.
American Nurses Association (ANA). (2001). Code of ethics for nurses. Retrieved April 30, 2012 from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf
College and Association of Registered Nurses of Alberta (CARNA). (2005). Professional boundaries: a discussion guide and teaching tool. Edmonton: CARNA.
DeWolf Bosek, M.S. and Savage, T. A. (2007). The ethical component of nursing. Philadelphia: Lippincott.
Greene, J. D., Morelli, S. A., Lowenberg, K., Nystrom, L. E, and Cohen, J. D. (2008). Cognitive load selectively interferes with utilitarian moral judgment. Cognition, 107(3), 1144-1154.
Schwartz, B. (2009). An innovative approach to teaching ethics and professionalism. Journal of the Canadian Dental Association, 75(5), 338-340.
Sheets, V. R. (2000). Staying in the lines: teach nurses how to maintain professional boundaries, recognize potential problems, and make better care decisions. Nursing Management, 31(8), 28-30, 32-34.
van Merrienboer, J.J.G., Sweller, J.(2005). Cognitve load theory and complex learning; Recent developments and future directions. Educational Psychology Review, 17(2), 147-177.