MAINTAINING PROFESSIONAL BOUNDARIES IN THE PSYCHIATRIC NURSE - CLIENT THERAPEUTIC RELATIONSHIP A GUIDELINE FOR REGISTERED PSYCHIATRIC NURSES
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This guideline has been developed by the College of Registered Psychiatric Nurses of Alberta (CRPNA) to provide advice to registered psychiatric nurses and the public of Alberta on what is the expectation of the CRPNA of its registrants maintaining appropriate professional relationships with their clients. Registered Psychiatric Nurses must be aware of their professional responsibility to maintain appropriate personal, sexual and financial boundaries in relationships with current clients, former clients and their families.
The mandate of the CRPNA is to protect the public of Alberta by setting standards of clinical competence and ethical conduct for registered psychiatric nurses. The Psychiatric Nurses Standards of Practice (2013) and the Standard of Practice Maintaining Professional Boundaries and Preventing Sexual Abuse (2019) and the Code of Ethics provides the framework for safe, competent, ethical and responsible psychiatric nursing practice that protects public safety.
This guideline will provide more detailed guidance on professional boundary issues and how they should be managed. It is impossible to provide guidance for every situation and it is expected that registered psychiatric nurses develop and use their own professional and ethical judgement and seek the advice of colleagues, managers, supervisors or their professional college when issues arise in relationships with clients.
Different cultures may have different expectations and understanding of relationships and boundaries. Culturally safe psychiatric nursing care involves balancing power relationships in the practice of psychiatric nursing so that every client receives effective treatment and care to meet their health/mental health care needs that is culturally competent and culturally responsive.
The CRPNA recognizes that registered psychiatric nurses (RPNs) are members of their communities and may have pre-existing relationships with some clients. The CRPNA is aware that for many clients establishing connections and relationships of trust are an important element of providing safe, competent and ethical psychiatric nursing care. This guide will provide advice on establishing and maintaining those professional boundaries.
The practice of psychiatric nursing occurs within the four domains of direct practice, administration, education and research. A client is anyone to whom an RPN provides service. In direct clinical practice, a client may be an individual, family, group, or a community that participates with RPNs in mental health/health promotion, illness prevention, and rehabilitation. In the domains of administration, education and research a client may include students, staff and research subjects.
The fundamental principle of psychiatric nursing practice is the therapeutic relationship between the client and the RPN. Establishing, maintaining and terminating this professional therapeutic relationship is the responsibility of the RPN, not of the client and every action or behavior of the RPN must be for the benefit of the client and not for personal gain of the RPN. RPNs must recognize that trust, respect and empathy are essential in the RPN-client relationship and must always be present. RPNs must be aware that in all their relationships with clients they have a greater power because of their authority, influence as a health care professional, their specialized knowledge, access to privileged information about the client and their role in supporting clients and those close to them when receiving care. The client does not have access to the same degree of information about the RPN as the RPN does about the client thereby increasing the power imbalance of the relationship. The RPN may also have a professional relationship with the client’s family and others close to that client that may increase the client’s vulnerability.
The power imbalance is increased when the client has limited knowledge, is made vulnerable by their health/mental health circumstances or is part of a vulnerable or marginalized group. Some particularly vulnerable groups are children, frail elderly, and those with a mental illness/addiction or disability. Clients must be able to trust the RPN to protect them from harm and promote their choices and RPNs must ensure that their own personal, sexual or financial needs are not influencing interactions between themselves and their clients. RPNs have a professional responsibility to recognize that clients may read more into a therapeutic relationship with the RPN and seek to have personal or sexual needs met. It is the responsibility of RPN when this occurs to recognize and maintain the appropriate professional boundary of the therapeutic client relationship. The RPN has the responsibility and accountability of knowing what constitutes appropriate professional practice and to maintain professional and personal boundaries. The client is in an unfamiliar situation and may not be aware of the boundaries of a professional relationship. The professional onus rests on the RPN to maintain a therapeutic relationship based on plans of care and goals that are therapeutic in intent and outcome. It is the RPN who must assist the client to understand the boundaries of a professional therapeutic relationship.
The zone of helpfulness is the center of a continuum of professional behavior. This is where the majority of interactions between a registered psychiatric nurse and client should occur for effectiveness and safety. On the right-hand side in the over involvement includes inappropriate relationships with the client and or their family members. Under involvement on the left side of the continuum includes distancing, disinterest, coldness and neglect. These behaviors can be seen as boundary issues but will not be discussed in detail as the focus of this document will be on the over involvement end of the continuum.
A pre-existing relationship could be described as being in an intimate relationship or just knowing the client by being a neighbour, acquaintance or even a business associate. The RPN must be aware of the potential for boundary confusion (by the RPN or the client) and possible harm that could be done. In situations where an RPN must provide care to close friends or family members it is rarely possible for the nurse to maintain enough objectivity about the person to enable a truly professional relationship to develop. In these situations, the RPN must clarify and if necessary, communicate this new professional relationship with the person in order to provide appropriate nursing care and declare it to the other members of the team and document in the client’s record. Where possible the responsibility of care should be reassigned as soon as possible to another nurse. In a pre-existing relationship it can undermine professional judgment and objectivity and it is critical that RPNs distinguish between “being friendly” and being friends. Clear boundaries must be established identifying when they are acting in a personal role and when they are acting in a professional role. By establishing these boundaries, the RPN protects the confidentiality of the client and protects their own personal integrity. There are times when an RPN may have to care for family or friends in an emergency or where they live in very small remote or rural areas and there is limited access to other health care providers to turn over care to. When an RPN has no option other than to care for a family member or close friend care should be handed over to another appropriate care provider when it becomes practical. In an emergency where care cannot immediately be handed over, all care should be documented including the RPNs personal relationship. Even in this situation the RPN needs to recognize when they may need to pass care on i.e. when they feel uneasy and are losing clarity, their professional judgment may be compromised, or they are experiencing strong emotions as a close loved one. RPNs need to be clear about their role as a professional and their role as a relative or friend.
In small rural and remote communities there is a natural overlap and interdependence of people living and working together. When someone in the community requires health/mental care, the RPN must keep themselves safe by clarifying the shift from a personal to a professional relationship in an open and transparent way. The RPN must ensure the person’s care needs are first and foremost and they must manage privacy issues appropriately. The RPN may be approached for information about the client in a grocery store by a concerned neighbour and the RPN has a responsibility and accountability to protect the client’s privacy. Whenever possible the client should be given a choice of nurse if they know the RPN from a prior relationship. When the RPN is off duty and the client requests information about care, the RPN would state they are not the client’s primary care giver at this time and refer the client immediately back to their appropriate on duty nurse. It is important to remember that small communities are not limited to rural or remote areas they can include small or discrete communities within large urban centers (i.e. religious, LGBTQ +, indigenous, or military communities).
It is important to maintain professional boundaries in the use of all forms of social media and electronic communication. Keep your personal and professional life separate as far as possible. Avoid online relationships with current or former clients. Do not use social media platforms to build or pursue relationships with former or current clients. Text messaging can be an appropriate form of professional communication (i.e. to remind clients to take medication or upcoming appointments). Text messaging as part of an employer’s requirement should also include ensuring staff are aware of professional boundaries and that any communication via text is not misinterpreted by the client as anything but a reminder and that the texting is not used to build or pursue personal relationships. Use of any form of electronic communication for employment purposes must follow all employer requirements.
Boundary issues can arise when an RPN becomes “over involved” with a client or family/family member. The RPN may think they are helping the client, family/family member by developing a friendship or close relationship. This boundary crossing has the potential to harm the client by changing the focus from the therapeutic needs of the client to meeting the RPNs own needs i.e. to be “special” or helpful or needed or to be close to someone or to have other personal, financial or sexual needs met. They have the potential to harm the client by increasing their vulnerability or dependence in the relationship with the RPN and could be detrimental to their health outcomes by compromising the psychiatric nurse’s objectivity and professional judgement. The harmful consequences may not be recognized or experienced until much later.
RPNs can reduce the risk of boundary transgressions by:
- Maintaining the appropriate boundaries of the psychiatric nurse-client relationship, and help clients understand when their requests are beyond the limits of the professional relationship.
- Developing and following the comprehensive plan of care with the client.
- Involving other members of the health care team in meeting the client’s needs
- Ensuring that any approach or activity that could be perceived as a boundary transgression is included in the plan of care developed by the whole health care team i.e. coffee counselling sessions.
- Recognizing when there may be an increased need for vigilance in maintaining professionalism and boundaries in certain practice settings i.e. rural and remote locations, when care is provided in a person’s home and the RPN may become involved in the family’s private life and the need to recognize when the RPNs behavior is crossing the boundaries of the professional relationship.
- Knowing when to consult with colleagues and/or the manager /or regulatory College in situations where it is unclear whether the behavior may cross a boundary of the professional relationship, especially circumstances that include self-disclosure or giving a gift or accepting a gift from a client.
- Documenting individualized information in the client chart regarding incidents where it was necessary to consult with a manager or colleague about uncertain situations.
- Considering the cultural values of the client in context of maintaining boundaries and seeking advice when unsure.
- Knowing when to raise concerns if the RPN believes that they may be close to crossing the boundary or that they may have already crossed a boundary.
- Discussing with the client the nature of a therapeutic relationship if they believe the client is communicating or behaving in a way that indicates they want more than a professional relationship.
- Knowing when to communicate with other colleagues or the manager when you believe another colleague appears to have transgressed boundaries with a client or the client is behaving in an appropriate manner towards that nurse.
The following are a few warning signs to indicate that the boundaries of a professional therapeutic relationship may be being crossed and that an inappropriate personal or sexual relationship may be developing are:
- The RPN self discloses feelings and aspects of their personal life to the client beyond what is necessary for care.
- The RPN becomes emotionally close to a client or regards the client as someone “special”.
- The RPN attempts to see the client or the client attempts to see the RPN outside of the clinical setting or outside normal working hours or after the professional therapeutic nurse-client relationship has been terminated.
- The RPN frequently thinks of the client when away from work.
- The RPN receives gifts or continues contact with the client after the care episode or therapeutic relationship has concluded, this includes the RPN buying and giving gifts to the client.
- The RPN provides the client with personal contact information.
- The RPN denies that a client was in their care in the past.
- The RPN accesses the client’s health record without any clinical justification.
- The RPN gives or accepts social invitations from the client (current and former).
- The RPN texts or uses any form of social media or electronic communication to communicate in a way that is not clinically focused.
- The RPN touches the client more than is appropriate or necessary for care provided.
- The RPN includes sexual context in interactions with the client or in relation to their partners, family or friends.
- The RPN changes their personal work style of dress when working with a particular client.
- The RPN participates in flirtatious communication, sexual innuendo or offensive language or black humor with a client.
- The RPN is unable or reluctant to conclude the professional therapeutic psychiatric nurse-client relationship.
- The RPN fosters dependency in the client and does not encourage self-management.
Sexual relationships with current clients or former clients that the RPN has engaged in a psychotherapeutic relationship are never appropriate. They are unacceptable because they can cause significant and enduring harm to the client, damage the clients trust in the RPN, damage the publics trust in nurses, impair professional judgment and influence decisions about care and treatment to the detriment of the client’s well-being. It does not matter how consensual this type of relationship may seem, there is a power imbalance that will always mean that there is the potential for abuse of the RPNs professional position and harm to the client.
There is always a reasonable expectation that any professional relationship will not be exploited in any way by the RPN to have their own needs met. There may be an occasion where an RPN may find themselves attracted to a client’s family or friend. It is the RPNs responsibility to ensure that they never act on these feelings and recognize the harm that any such action would cause.
There is no arbitrary time limit that makes it safe for an RPN to have an intimate or sexual relationship with a former client. The sexual relationship may be influenced by the previous therapeutic relationship where there was a clear imbalance of power. There is also potential for the client to be harmed by the relationship especially if this professional psychiatric nurse-client relationship included any psychotherapeutic treatments or interventions. These types of sexual or intimate relationships are never appropriate no matter how long ago the professional psychiatric nurse-client relationship ceased.
Things to consider when deciding if a relationship could be appropriate:
- How long the professional therapeutic psychiatric nurse-client relationship lasts (the longer it lasts, the less appropriate a personal relationship becomes). Assisting a client with an episodic or temporary problem (flu clinic) is different than providing long-term care for a chronic health/mental health condition.
- The nature of the relationship in terms of was there a significant power imbalance and whether the RPN could be perceived as using their previous influences to begin a personal relationship.
- The vulnerability of the client at the time of the professional relationship and if they (client) are still vulnerable (including the client’s psychological, physical and character traits).
- Can the RPN exploit the knowledge they hold about the client because of the previous professional relationship.
- Will the RPN be caring for the client, their family or family members in the future?
When the RPN is privy or was privy to personal information that could compromise the client if used out of a professional setting (whether the relationship was a therapeutic one or involved emotional support) or if the client was a previous mental health consumer or has an intellectual disability it is never appropriate for a sexual or intimate relationship to develop. The same considerations should apply to relationships with the family members of former clients. There could be potential to harm the client or other family members. In situations that are unclear the RPN should always seek advice from their regulatory college.
Accepting gifts, favors or hospitality may compromise the professional relationship with a client. Gifts could be interpreted as the RPN gaining personal benefit from their position, or the RPN taking advantage of a vulnerable client, or an attempt to gain preferential treatment, or an indicator of a personal or emotional relationship.
Clients should never form the impression that their care is dependent on gifts or donations of any kind.
Cash gifts should never be accepted. Most organizations have clear policies concerning the receipt of gifts, and all RPNs should follow this policy. RPNs should not give gifts to their clients as the client may feel obligated to give something in return or interpret the gift as an indicator of a personal relationship.
It is never appropriate to ask for or accept loans or bequests from anyone in your care or anyone close to the client. Do not enter into a business agreement with a client or former client that may result in personal benefit.
RPNs observing any inappropriate conduct of colleagues, whether in practice, management, education, or research have both a responsibility and an obligation to report such conduct to an appropriate authority and to take other action as necessary to safeguard the client. Failure to take steps to prevent harm to a client may lead to disciplinary action being taken against the psychiatric nurse. If the psychiatric nurse is approached by a colleague who has displayed sexualized behaviour to a client, the first priority is the safety of the client, and then the psychiatric nurse must take appropriate steps without delay, including informing the employer and/or regulatory body or even the police if the psychiatric nurse has reason to believe that a criminal offence has been committed.
These actions must be taken by the RPN even if the client does not wish the matter to be pursued.
The following is a partial list of references used in compiling the information for this guideline, and CRPNA would like to thank all those who provided the expertise in developing the content of their documents and for sharing of information.
Australian Nursing and Midwifery Council (2010), A nurse’s guide to professional boundaries. Australia, Author.
Australian Nursing and Midwifery Council, Draft Background paper to the nurse’s guide to professional boundaries. Australia, Author
College and Association of Registered Nurses of Alberta (2011), Professional Boundaries for Registered Nurses: Guidelines for the Nurse-Client Relationship. Alberta Author.
College of Registered Psychiatric Nurses of Alberta (2013) and (2019) Standard of Practice Maintaining Professional Boundaries and Preventing Sexual Abuse and Standards of Psychiatric Nursing Practice and Code of Ethics, Alberta Author.
College of Registered Psychiatric Nurses of Manitoba, Professional Boundaries in Psychiatric Nursing. Manitoba, Author.
Council for Healthcare Regulatory Excellence (2008). Clear sexual boundaries between healthcare professionals and patients: responsibilities of healthcare professionals.
College of Nurses of Ontario (2006). Therapeutic Nurse-Client Relationship. Ontario, Author.
Medical Council of New Zealand (2009). Sexual boundaries in the doctor-patient relationship.
Social media and the nursing profession: a guide to online professionalism for nurses and nursing students. Nursing Council of New Zealand (2007). Author.
Boundaries: Boundaries are limits that protect the space between the professional’s power and the client’s vulnerability. Boundaries define and separate professional roles from other roles. Boundaries are the limits that allow a safe connection between a professional and a client and are always based on the client’s needs (Peterson, M. 1992).
Client: Individual, groups, families, and communities.
Episodic Care: a single clinical encounter with the patient for a defined health care need, where neither the nurse nor the patient has the expectation of continuing care and the therapeutic and professional relationship. The nurse is required to document this clinical encounter on the patient’s health record.
Power Imbalance: the power of the psychiatric nurse comes from the professional position and the access to the private knowledge about the client.
Psychotherapeutic: planned and structured psychological, psychosocial, and/or interpersonal interventions influencing a behavior, mood, and/or emotional reactions to different stimuli (College of Nurses of Ontario, 2006).
Registered Psychiatric Nurse: refers to regulated members of CRPNA, including psychiatric nurses, and those on the temporary and courtesy registers.
Therapeutic Relationship: An interpersonal process that is purposeful, goal directed and focused on achieving outcomes in the best interest of the client.
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