Home - Nurse Practitioners - Learning resources - Boundaries in the Nurse-Client Relationship - Understanding boundaries
Nurse-client relationships are therapeutic, focus on client needs and are defined by professional boundaries. Professional boundaries are the spaces between the nurse’s power and the client’s vulnerability. These boundaries create a zone of helpfulness - allowing for a safe connection between you and the client. One way to look at these boundaries is as a continuum or range of behaviors. At one end is the zone of over-involvement and at the other, under-involvement. The zone of helpfulness or therapeutic relationship is in the middle. Client harm can occur at either end of the continuum.
As the nurse, you are always responsible for establishing and maintaining appropriate boundaries, regardless of how a client behaves. Some boundaries are clear-cut. Others are less clear and require your professional judgment. It’s important that you are able to recognize when a professional relationship is slipping into the non professional realm and take immediate action.
Components of nurse-client relationships
Power, trust, respect and professional intimacy are the key components of nurse-client relationships. Regardless of the context or length of an interaction, these components are always present.
The power of the nurse comes from the professional position, the access to private information about the client and the client’s need for care. Clearly established boundaries allow the nurse to manage this power differential and meet the client’s therapeutic needs within a safe interaction.
Within the nurse-client relationship, a power imbalance exists between you and your client. The client‘s need for your professional expertise makes them vulnerable. Your influence, access to information, and ability to advocate for them can add to their vulnerability. Some clients are particularly vulnerable, such as those with:
substance use or dependency disorders
To effectively manage this power and set appropriate boundaries, you need to:
recognize that the power exists
understand the elements of the power
accept that these elements create a power imbalance
use this power appropriately
Inadvertent boundary crossings or violations can result from attempts to minimize or equalize power. Although these crossings or violations are unintentional, they may harm the relationship and client. Using power appropriately allows you to focus on maintaining the client’s safety and dignity.
Establish and maintain appropriate professional boundaries.
Communicate the boundaries to the client, anticipate and manage client expectations.
Recognize situations where the power of the nurse goes up, e.g. behind closed doors. (and discuss with the client how to manage this)
Distinguish between personal and professional relationships, e.g. maintain a personal distance while creating professional closeness, separate personal values and beliefs from professional ones.
Don’t interact with clients on personal social media sites and use caution with former clients.
Trust is integral to a therapeutic relationship. Your clients must trust you will act in their best interest at all times. Trust can be fragile – it’s important to keep promises to your client. If trust is breached, it may be difficult or impossible to re-establish.
Nursing Strategies:
Clearly define your role and service parameters with your client.
Provide clients with all the information they need to make informed decisions.
Self-disclose only for therapeutic purposes and only if doesn’t adversely affect the client’s care and well-being. Limit the amount, duration and nature. (NCSBN, 2012).
Communicate respectfully in all interactions with or about clients.
Be transparent in all your actions with your clients and former clients.
Respect is the recognition of the inherent dignity, worth and uniqueness of every individual, regardless of socio-economic status, personal attributes and nature of the health problem. Respect is basic in a therapeutic relationship—to knowing the client as an individual with valued priorities, needs and wants.
You must treat all clients equally and in an unbiased, non-judgmental manner—even if a client evokes strong negative emotions. Maintaining a respectful relationship requires recognizing your own personal values and biases and taking steps to minimize potential negative effects.
Seek to understand your client’s behavior and their perspective of the care they are receiving.
Use a client-centered approach and collaborate with clients in planning and prioritizing care.
Demonstrate respect by using therapeutic communication with the client such as active listening, reflecting, empathy, counseling and touch.
Acknowledge your own emotional response to the client and take steps to resolve these (e.g. explore strategies to support connecting with the client, check your own attitude and recognize biases, consult with manager and/or trusted colleague) (Elder, Ricer, Tobias, 2006).
Maintain an appropriate emotional distance to ensure objectivity, without becoming disengaged.
Professional intimacy is inherent in the type of care and services that nurses provide. This includes physical activities and psychological, spiritual and social elements of care. Access to a client’s personal information contributes to this.
Boundaries guide you in what you should say and do – as well as what you should not. They help to safeguard both you and your client by preventing actions and intention from being misunderstood.
Remember, it is always the nurse’s responsibility to maintain appropriate professional boundaries with clients and their significant others.
Provide clients with adequate privacy.
Explain your actions and obtaining client consent before initiating any activities.
Touch clients only in a manner consistent with accepted standards of nursing practice.
Don’t discuss any personal sexual or romantic activities, relationships or fantasies with clients or others in the work setting.
Don’t hug, kiss or caress a client without establishing therapeutic intent and considering context, appropriateness and client permission.
Be aware of the potential impact of your manner of dress on your client(s) and dress in a manner that maintains professional boundaries.
Consider if a client-specific care plan related to professionally intimate activities would be helpful to ensure both client and staff safety.
Boundary crossings are brief excursions across professional lines of behavior that may be inadvertent, thoughtless or even purposeful, while attempting to meet a special therapeutic need of the client.
Some individual behaviours may appear harmless but when put together, form a pattern indicating a boundary has been crossed.
Examples of boundary crossings:
Calling the client’s family to access client information when the client did not want them involved.
Driving a client to do their banking because you were going that way.
Boundary violations can result when there is confusion between the needs of the nurse and those of the client. Inappropriate relationships may start with something benign then gradually progress until the nurse has clearly violated a boundary.
Boundary violations can cause distress for the client, which may he/she may not recognize or feel until harmful consequences occur.
Examples of boundary violations:
Visiting with a client when not at work
Asking your client, the accountant, the best way to invest money
Referring your client for foot care but only providing your own business card
Professional sexual misconduct is an extreme form of boundary violation and includes any behavior that is seductive, sexually demeaning, harassing or reasonably interpreted as sexual by the patient (e.g., making a joke about breast size).
Professional sexual misconduct is an extremely serious violation of the nurse’s professional responsibility to the patient. It is a breach of trust.
Warning signs of boundary issues
The following behaviours can signal potential boundary issues. These signs indicate a need to reflect on the nurse-client relationship and clarify boundaries.
Over involvement with a client
Thinking about client frequently when you’re away from work.
Giving preferential care or time to the client and putting their care needs above others.
Feeling responsible for the client’s outcomes or lack of progress and being irritated by treatment delays or barriers.
Having more physical contact than is required or appropriate.
Spending breaks or time off with the client, seeking social contact and providing personal information such as your email address or phone number.
Participating in personal conversations, flirtations, off-color jokes or sexual innuendos.
Feeling a sense of excitement, longing, romantic or sexual thoughts related to the client.
Hiding your relationship with the client from others.
Receiving feedback from others that your behaviour is overly familiar or intrusive.
Refusing to transfer care of a client to another provider when therapeutically indicated.
Under involvement with a client
Delaying care or treatment (e.g. waiting to answer a call bell or delaying a needed prn medication unnecessarily).
Taking short cuts in a client’s care (e.g. neglecting to wash your hands or skipping a dressing change).
Blaming the client for lack of progress.
Being unnecessarily rough when providing care.
Using disrespectful, demeaning, insulting, or humiliating language or tone.
Inadequately draping a client during a procedure
Avoiding the client to a degree that interferes meeting care needs.
Withholding information the client needs to make an informed decision.
​Some boundaries are absolute and must never be violated. Others require judgment and careful consideration of the context. Some behaviors, while unacceptable in most contexts, may be acceptable and appropriate in special circumstances. ​​
Maybe you’re uncertain or wonder if you’ve crossed a boundary with your client. Perhaps someone points out how others could view your behavior. If you’re concerned a potential boundary issue -- take steps to address it right away. Reflecting on the situation, your behavior and exploring concerns can help you understand your own feelings and motives and recognize the effect of your actions on the client. Consulting with a knowledgeable and trusted colleague is an objective place to start.
As a nurse, you are responsible and accountable for your nursing actions and professional conduct. If you’ve breached a professional boundary, you must take steps to restore the boundary appropriately. It may be necessary to withdraw from or end the relationship.
Behaviour outside the zone of professional behaviour requires intervention and/or reporting. If you are unsure if reporting is required, call the Nursing Concerns Coordinator to discuss.
In situations where you have both a personal and professional relationship with a client, you are acting in a dual role. When you have a personal relationship with someone, you may find it difficult to be objective enough to also have an effective professional relationship. You may have difficulty separating personal feelings, values and beliefs from your professional and ethical obligations.
BCCNM recommends that when possible nurses avoid dual roles and transfer overall responsibility for care to another health care provider.
If you are unable to transfer care or choose to provide some care, you will need use extreme caution. Make sure: ​
all available alternatives are explored with the client and the health care team
the client is fully informed and consents without feeling pressured or coerced
you make it clear to everyone concerned (the client, client’s significant others, other health care team members and yourself) when you are acting in a personal role and when you are acting in your professional role
you continue to meet all professional and ethical standards (especially privacy and confidentiality, consent, documentation, conflict of interest, duty to provide care)
you follow any agency policies related to caring for friends and family