Nurses and Relationships, Boundaries

Being a nurse requires establishing professional boundaries. A nurse who crosses these boundaries may be subject to various forms of disciplinary action. In some cases, crossing professional boundaries can even put a nurse at risk of losing their license.

Has someone accused you of professional boundary-crossing? If so, the Lento Law Firm Professional License Defense Team can help you protect your career.

Our knowledgeable attorneys can assist you in navigating an investigation, appealing a licensing board's decision, and any other processes you might otherwise have to navigate on your own when your nursing license is on the line. Get started today by submitting our online contact form or calling our offices at 888-535-3686 to learn more about what we can do for you.

The Importance of Professional Boundaries in Nursing

It's essential to understand that different state licensing boards may have somewhat different standards regarding professional boundaries for nurses. Even if an act qualifies as “boundary crossing” in two different states because those states have different licensing boards, the disciplinary action a nurse faces in one state may not be the same as in another.

That said, the National Council of State Boards of Nursing (NCSBN) offers general guidance on this topic that can apply across all states. Per the NCSBN, nurses should keep the following points in mind throughout their interactions and professional relationships with patients:

• The nurse-patient relationship involves a power imbalance: A power imbalance tends to be a natural component of a relationship between a nurse and their patients. First, it's important to consider how the nature of a patient's condition can impose certain overall limitations on their ability to determine the nature of their relationship with a nurse. Perhaps more critically, a nurse is often privy to information about a patient, which can result in a nurse having power over said patient. Nurses must exercise this power according to widely accepted professional ethics standards, their employer's policies, and their own judgment.
• The needs of the patient are the priority: There may be instances when it's acceptable for a nurse to engage in minor boundary crossing. However, they may only do so to serve the needs of the patient. The NCSBN encourages nurses to guard against crossing boundaries in the vast majority of circumstances. If a nurse does cross boundaries to serve a patient's needs, they should refrain from doing so repeatedly. A nurse must also consider how certain forms of boundary crossing are more significant than others.
• Nurses must consider the actions and behaviors of their peers: Nurses should monitor their peers to ensure they're not crossing professional boundaries. Doing so is particularly important if a nurse supervises others. The NCSBN states nurses should promptly report any instances in which their colleagues, peers, or anyone else violates the privacy and confidentiality rights of patients.

These suggestions indicate nurses may sometimes lack strong guidance regarding when crossing boundaries is and isn't appropriate. The NCSBN even points out that it's not uncommon for boundary crossings to be unintentional.

Someone accusing a nurse of crossing professional boundaries or violating professional ethics in a similar way doesn't automatically mean the nurse intentionally engaged in inappropriate behavior. Although the specific ways we serve our clients vary depending on the specifics of their cases, this is a point the Lento Law Firm Professional License Defense Team may consider when building your defense.

Social Media and Professional Boundaries for Nurses

Professional boundaries in nursing have long been a complex and nuanced topic. It's only grown more complex in the age of social media.

The NCSBN points out that certain types of social media behavior can qualify as crossing professional boundaries. Specifically, if a nurse references a patient or case they're working on, they may cross a professional boundary when doing so. At the very least, they run the risk of violating patients' rights and confidentiality.

The NCSBN offers the following recommendations to help nurses limit their chances of violating patient confidentiality on social media:

• Never share any patient-related images via social media or other such forms of electronic media.
• Never transmit via social media any information that one could reasonably assume might violate a patient's confidentiality or privacy rights. Even sharing information that could potentially embarrass a patient is a violation.
• Generally, don't post or share any patient information that was acquired as a result of the nurse-patient relationship. It's only acceptable to disseminate this type of information when doing so is necessary to provide patient care.
• Don't post or publish a patient's name or any other information that someone could use to identify a patient.
• Don't assume that adjusting privacy settings is sufficient to guard against violating a patient's rights to confidentiality and privacy. Even if a nurse can control who sees what they share on social media, they can't prevent their social media followers from disseminating the content or information they publish.
• Don't disparage patients on social media. Doing so is inappropriate even when not specifically identifying a patient by name.
• Don't take photos or videos of patients using your personal device unless doing so is necessary for patient care and there is no alternative. Refer to your employer's guidelines for taking photos or videos of patients so that you do so properly and only when necessary.
• Establish professional boundaries in the nurse-patient relationship and maintain these professional boundaries on social media. If a patient attempts to initiate contact with a nurse via social media, that doesn't automatically mean it's acceptable for a nurse to reciprocate. Nurses should evaluate every situation carefully and refer to employer policies to determine how to respond if patients or former patients attempt to reach out or establish friendships online.

Understanding the Continuum of Professional Behavior for Nurses

The NCSBN describes the nurse-patient relationship as a continuum of professional behavior. The three major categories of this continuum are:

• Under-involvement: Under-involvement occurs when a nurse abandons or otherwise neglects their patient.
• Therapeutic relationship: A proper therapeutic relationship is one in which a nurse tends to a patient's needs and fulfills their professional responsibilities and duties without crossing professional boundaries.
• Overinvolvement: Overinvolvement occurs when boundaries are crossed. As this overview explains, crossing a professional boundary as a nurse can take many forms.

The NCSBN also points out that what constitutes a professional boundary crossing can depend on the context. Factors a nurse may have to account for when determining whether their behavior constitutes overinvolvement (or under-involvement) include:

• The setting in which a patient receives care (such as their home vs. a hospital)
• The individual needs of the patient
• The nature of the therapy/treatment a patient is receiving
• Community influences

Nurses must often exercise their own judgment when determining whether their actions constitute boundary crossing. Some might argue this places an unreasonable burden on a nurse.

Nurses are human beings. They're capable of making lapses in judgment despite acting with the best intentions. If you're a nurse who's facing license suspension, license revocation, or another potential form of disciplinary action due to allegedly crossing a professional boundary, mounting a proper defense is critical. The Lento Law Firm Professional License Defense Team can assist with this task.

Ways to Guard Against Crossing Professional Boundaries as a Nurse

The NCSBN offers several tips and recommendations nurses can keep in mind to reduce their chances of accidentally crossing professional boundaries. They include:

• Avoid treating patients you know: A nurse may not always have the freedom to determine who they do and don't treat. However, to the best of their ability, a nurse should strive to avoid situations requiring them to treat patients with whom they may already have personal, professional, or business relationships.
• Consider whose needs an action serves: Once more, it can be difficult for a nurse to constantly monitor their actions to determine whether they fall into the therapeutic relationship category along the nurse-patient relationship continuum. A nurse who isn't sure whether a particular action or behavior constitutes boundary-crossing should ask themselves who the action serves. If it serves the needs of the patient, it may be appropriate. It may be inappropriate if it primarily serves the needs of the nurse.
• Determine whether a former patient still needs care: Some might assume professional boundaries no longer exist when a patient is no longer receiving care. However, it's vital to consider whether a patient will continue to need some form of treatment or whether they may need additional care in the future. For example, former patients with mental or chronic health issues might become patients again in the future as their needs change and develop.

Sexual Misconduct and Professional Boundaries in Nursing

The NCSBN considers sexual misconduct to be among the most extreme forms of professional boundary-crossing a nurse can engage in. According to the NCSBN, sexual misconduct may include (but is not necessarily limited to) the following:

• Engaging in any behavior that could be interpreted as seductive
• Engaging in sexually demeaning behavior
• Harassing a patient
• Engaging in any form of behavior that a patient could reasonably interpret as sexual in nature

Taking patient complaints seriously is essential. That said, when what does and doesn't constitute sexual behavior is left open to interpretation, it becomes possible for nurses to face challenges due to patient misinterpretation. A patient who believes a nurse acted sexually toward them may not be interpreting the situation correctly.

Maybe you're the target of a patient complaint because they falsely believe you engaged in a form of sexual behavior with them. While you may be certain this is just a case of misinterpretation; you can't be certain your state's licensing board will see it that way.

Protect yourself by enlisting the assistance of attorneys with experience addressing such matters. If a patient claims you've attempted to engage them sexually, our Professional License Defense Team at the Lento Law Firm can help.

Patient Consent, Sexual Relationships, and Professional Boundaries in Nursing

Entering into a sexual relationship with a patient is an obvious example of boundary crossing. Per the NCSBN, it doesn't matter whether a nurse has received patient consent or even whether a patient has initiated sexual contact—having a sexual relationship with a current patient is almost always an example of crossing professional boundaries. However, a nurse may not be crossing any boundaries if they have an existing sexual relationship with a patient that precedes the nurse-patient relationship.

The topic is more complex when an individual is no longer a nurse's patient. Again, the NCSBN encourages nurses to consider whether former patients may become future patients before deciding to engage with them on a personal, sexual, or romantic level. Other factors a nurse should account for before entering into a sexual and/or personal relationship with a former patient include:

• How long ago the nurse-patient relationship ended
• The type of treatment a patient received (providing long-term care to a patient with a major health condition is different from providing basic, short-term care to a patient with a minor health issue)
• The type of personal information a nurse had access to when an individual was their patient
• Whether entering into a sexual, personal, or romantic relationship with a former patient will put them at risk in any capacity

The NCSBN also addresses the fact that the size of a nurse's community may be a factor influencing their decision when entering into a personal relationship with a former patient.

A nurse in a small, rural community doesn't have access to the same network of potential friends and dating partners as a nurse practicing in a major city. They may account for this when deciding whether to cultivate a personal relationship with a former patient.

A nurse in a rural community must also consider whether their existing relationship with an individual represents a conflict of interest should that individual become their patient. To the extent that they can, nurses should avoid treating patients with whom they already have relationships. Actually, striking this balance can be difficult in a small community where many people know each other, and nurses may be in relatively short supply.

Such complexities serve as a reminder that it's not always easy for a nurse to determine with complete certainty whether the nature of their relationship with a current or former patient represents a crossing of boundaries. If you're facing disciplinary action because of your relationship with a patient, that doesn't necessarily mean you intentionally violated professional ethics. Protect yourself and your career with help from the experienced attorneys with the Lento Law Firm Professional License Defense Team.

Red Flags and Professional Boundaries in Nursing

Another way to potentially guard against crossing professional boundaries as a nurse is to monitor for red-flag behaviors. These are often behaviors that don't necessarily always constitute boundary crossing themselves but could indicate professional boundaries are in danger of being crossed.

Nurses should monitor their own behaviors for these red flags. They should also pay attention to whether their colleagues are engaging in such behaviors. Per the NCSBN, common red flag behaviors among nurses who cross professional boundaries include:

• Discussing personal issues with patients
• Discussing intimate issues with patients
• Behaving in any way that could be reasonably interpreted as flirting with patients (even if the intention wasn't to flirt)
• Keeping secrets on behalf of a patient or with a patient
• Spending more time with a patient than is necessary for their care
• Disparaging one's colleagues, employer, and/or employment setting with a patient and/or their family
• Engaging in any form of favoritism
• Meeting with a patient outside of work
• Meeting with a patient in any setting not used to directly provide a patient with care

A patient's behavior may also include red flags that indicate they're developing an unprofessional relationship with a nurse. For example, perhaps a patient insists that only one nurse be involved in their care. While it's acceptable for patients to have preferences, if a patient appears to have an unreasonably strong preference for one nurse over all others, this could be a sign that a relationship is becoming unprofessional.

A nurse can also monitor their thoughts and attitudes toward patients to determine if they may be crossing boundaries. For example, the NCSBN lists “believing that you are the only one who truly understands or can help the patient” as another common red flag. If you think you're the only one capable of providing a patient with the care they need, your relationship with them may be moving towards overinvolvement.

That said, it's worth keeping in mind that what does and doesn't constitute being “too close” with a patient can look different to different people. A colleague or other outside observer who monitors the relationship between a nurse and their patients may misinterpret certain interactions. Such misinterpretations could cause them to assume a nurse has crossed a professional boundary when they, in fact, have not.

Maybe this has happened to you. If a colleague or other such party has accused you of boundary crossing with patients, our Professional License Defense Team at the Lento Law Firm is on hand to help you guard against the potential consequences of these types of accusations.

Risk Factors for Crossing Professional Boundaries as a Nurse

Researchers have identified certain risk factors that may increase a nurse's odds of engaging in professional boundary crossing. According to the research, these risk factors particularly apply to the risk of crossing sexual boundaries. They include:

• Inexperience: As this overview has likely made clear, it can be difficult for a nurse to thoroughly understand whether certain behaviors qualify as crossing professional boundaries. Younger nurses who lack experience navigating certain professional situations may be more likely than others to make mistakes that qualify as boundary-crossing behaviors.
• Lack of education: Lack of education overlaps with lack of experience. Some nurses engage in boundary-crossing behaviors because they haven't been thoroughly educated on the topic.
• Chemical dependence and/or sex addiction: It may not surprise anyone to learn that research shows nurses who struggle with sex addiction may be more likely than others to engage in inappropriate sexual relationships with patients. Research also shows that a relatively significant percentage of nurses who engage in such relationships struggle with drug addiction or similar chemical dependence issues.
• Major life events: Researchers have also discovered that nurses may be at greater-than-usual risk of crossing professional boundaries when they are going through major life events. Examples include divorce, grief, and mid-life crises.

These risk factors certainly don't mean a nurse is guaranteed to cross professional boundaries. However, nurses should identify their own risk factors when questioning whether they are engaging in inappropriate behavior.

In some instances, identifying risk factors and taking steps to mitigate them can help when defending one's professional license. For example, perhaps a nurse with a substance abuse or dependence issue is facing allegations of misconduct. Said nurse could proactively take steps to address their substance abuse problem.

Every case is different. That said, it's not uncommon for licensing boards to consider these types of mitigating factors when determining whether to take disciplinary action against a nurse.

This touches on another reason to seek professional legal assistance if you're a nurse whose license is in jeopardy due to such allegations. Qualified attorneys may be able to help you identify steps you can take to make the right impression on a licensing board during an investigation.

Understanding Relationships With ‘Key Third Parties' as a Nurse

A nurse should not engage in a romantic or sexual relationship with a patient. However, some nurses may wonder whether they can engage in such relationships with the family, friends, or other loved ones of their patients.

According to the AMA Journal of Ethics, “key third parties” are parties with whom medical professionals may interact in connection with patient treatment. Common examples of key third parties include:

• Spouses
• Partners
• Parents
• Guardians
• Proxies

The AMA Journal of Ethics points out that the above may not be a complete list. In different circumstances, various types of individuals may qualify as key third parties. Someone may qualify as a key third party if a nurse's role allows them to offer any of the following:

• Information about a patient's treatment
• Advice about a patient's needs or care
• General emotional support throughout a patient's treatment

The AMA Journal of Ethics doesn't state that it's never appropriate for nurses and other medical professionals to get involved in personal or sexual relationships with key third parties. However, getting involved in such a relationship may be unethical if doing so involves exploiting a key third party's trust, emotions, vulnerability, etc.

For example, perhaps a nurse works at a pediatric clinic. Is it appropriate for that nurse to develop a romantic or sexual relationship with the parent of one of their patients?

According to the AMA Journal of Ethics, a medical professional should account for these factors before deciding whether to enter into a romantic or sexual relationship with a key third party:

• The nature of a patient's medical issue: A medical issue requiring a patient to undergo prolonged or otherwise significant medical treatment might render a personal relationship with a key third party inappropriate. If a medical issue is serious, a nurse may be deeply involved in a patient's care. It could be inappropriate for them to get involved with a patient's family members or close friends in these circumstances.
• The duration of the professional relationship: A nurse should account for the length of the professional relationship they have with a patient and a key third party before entering into a personal relationship with said key third party. Although this is by no means the only important factor in the equation, generally, the longer the professional relationship has lasted (or is likely to last), the less advisable it is for a nurse to get involved with someone close to a patient.
• The degree of emotional dependence: Again, a key third party may be someone who turns to a nurse for emotional support during a patient's treatment. A nurse may consider the degree to which a key third party relies on them when determining if a personal relationship is appropriate. If a key third party relies heavily on a nurse for emotional support, they may be vulnerable to being taken advantage of. A nurse should refrain from entering into a romantic or sexual relationship with a key third party when this type of power imbalance exists.
• The importance of the nurse's role in a patient's treatment: As always, a patient's needs are always most important. Entering into a personal relationship with a key third party could theoretically compromise a nurse's ability to offer a patient the quality treatment they need.

It also can't be stressed enough: State licensing boards can establish and enforce their own standards for professional behavior among nurses. Any nurse thinking about a romantic or sexual relationship with a key third party should check their state's and employer's policies to confirm they understand what they can and can't do.

Defending yourself because you've entered into a personal relationship with a patient's family member or friend can be an emotionally stressful experience. Navigating this experience may be much easier when you have assistance from lawyers who can help you guard against accusations of misconduct. Get in touch with the Lento Law Firm Professional License Defense Team for more information.

Potential Defenses When a Nurse is Accused of Crossing Professional Boundaries

Professional boundary crossing can take many forms for nurses. Thus, the way in which professional license defense attorneys build cases can also take many forms.

The following are just a few examples of common legal defenses when patients, colleagues, or others with relevant knowledge accuse nurses of crossing professional boundaries or otherwise engaging in inappropriate relationships with patients:

• The boundary crossing served a therapeutic purpose: Remember, the NCSBN points out there may be circumstances in which it's appropriate to cross professional boundaries in a minor capacity. Doing so may be appropriate if crossing professional boundaries serves a therapeutic purpose. A potential defense may be that a nurse evaluated the facts of a situation and reasonably determined that engaging in boundary-crossing behavior was necessary to serve the needs of a patient.
• A boundary crossing didn't cause harm: Some types of actions may technically qualify as “crossing professional boundaries” merely because they involve a nurse assisting a patient in a manner outside the scope of their employment. For example, a home health nurse might assist with other tasks around a patient's home, such as cleaning. A nurse may even accept a gift from a patient. While these examples may qualify as boundary crossing in certain contexts, they're unlikely to result in patient harm.
• The boundary crossing was unintentional: It may sometimes be possible to defend a nurse by pointing out that they crossed professional boundaries unintentionally. Depending on the nature of the alleged misconduct, showing that a nurse is guilty of nothing worse than human error could influence a case's outcome.

These are only a few examples. At the Lento Law Firm, members of our Professional License Defense Team will thoroughly consider all details of your case to tailor our defense strategy to your specific needs.

How the Lento Law Firm Professional License Defense Team Can Help a Nurse Accused of Crossing Professional Boundaries

Maintaining professional boundaries as a nurse requires striking a delicate balance. You want to provide patients with attentive care, but you don't want your relationships with them to become inappropriate.

Are you in danger of losing your license because someone has accused you of crossing professional boundaries? You need legal assistance if so.

Attorneys can help in many ways when accusations of misconduct threaten to derail a career you've worked hard for. Although this isn't a criminal case, we can defend you as if it were, pointing out flaws in the case against you.

We can also help you make critical decisions throughout the investigation and disciplinary processes. For example, you may have the option of negotiating with a licensing board to settle your case and avoid major disciplinary action. While attorneys can't make these decisions for you, we can help you understand your options.

The best way to learn more about how lawyers can help with a case like yours is to speak with them directly. For more information about how the Lento Law Firm Professional License Defense Team can help, call our offices at 888-535-3686 or contact us through our online form.