Perhaps when you read the title, your first thought was, “Oh great. Someone is going to tell me what I can and cannot do in my nursing practice.” As oncology nurses, we realize that if we do not have borders or “boundaries” for the care that we provide, it can be harmful to our patients, our coworkers, our organization, and us. Sometimes, however, a particularly special patient can tempt us to push or break our boundaries.
As a nurse who has worked in oncology my entire career and lost both of my parents to cancer, I can tell you that oncology is very rewarding. But it can also have its pitfalls. There are times (or will be times) when you become overinvolved and even underinvolved. Your goal is to remain in what is described as a zone of helpfulness that allows for a professional, therapeutic relationship to help meet the health needs of those under your care.
Your knowledge and skills as an oncology nurse, as well as access to confidential information, make the patient vulnerable and give you power. You might not like the word power, but it is real because you control the care you provide, you have access to private and personal information, and you have specialized knowledge about cancer and its treatment.
The National Council of State Boards of Nursing defines a boundary crossing as a “brief excursion across professional lines of behavior.” Your action may be unplanned and honestly intended to meet a patient’s or a caregiver’s need. Consider the following:
It seems like a harmless, kind gesture. But questions to ask yourself are:
1. Are there any real or perceived issues?
2. Can you reasonably do this for all the patients in your care?
3. How will your action affect your coworkers?
4. Will this be seen as favoritism?
Often we do not think about the downstream effects of our actions or how others might view them. We simply see a need and have an answer to how to meet that need. Your good intentions are not always in the best interests of the patient, the caregivers, your coworkers, or the organization.
At first, you may conclude that there is really no issue with this scenario. After all, it is just a small, kind thing you can do for your patient, right? You may also think that it could just remain a “secret” and that your coworkers will not know. Or you may not care if you are viewed as the patient’s “favorite” or “special” nurse. The problem is that one small gesture can lead to another and another—and possibly a boundary violation. It is also a possibility that this kindness can have repercussions by itself—the patient may start demanding you as a nurse or being dependent on you.
Boundary violations are potentially harmful actions that violate your professional relationship with patients. The most obvious violation is any sexual involvement with a patient. Boundary violations are often clear-cut, with damaging results. Boundary crossings, however, can be blurry, requiring your professional judgment and perhaps the professional advice of others.
So, what is the harm of a boundary crossing? A boundary crossing can damage your relationship with your patient, cause potential harm to other patients, put your colleagues in difficult situations, and cause unintentional risk for your employer. Small multiple boundary crossings can lead to a boundary violation, which can have legal consequences or loss of your hard-earned license.
Crossing boundaries can also affect you personally. Without clear boundaries, nurses have higher burnout, turnover, compassion fatigue, and moral distress and may even experience negative mental health issues like posttraumatic stress disorder. Oncology nurses, particularly younger or novice nurses, are at higher risk for turnover (41%) compared with other specialties (13%). So, it is important to learn skills to prevent, recognize, and manage boundary crossings.
Over the next few issues, we are going to explore common boundary crossings such as social media requests, using your own funds, and transporting or housing patients and caregivers. We want to discuss your concerns and provide different ways to handle these issues.
Boundary crossings happen to every nurse, especially oncology nurses, who may be with their patients for an extended period of time and develop a special bond. Like cancer, the key is prevention! We want to help you recognize early warning signs, conduct self-evaluations, and more carefully consider what is in your patient’s, colleagues’, and organization’s best interests.
Warning signs can provide insight that you are sliding on the continuum outside the zone of helpfulness toward non-helpful behavior. You will learn what to do if you think you are close to crossing or if you see a colleague heading outside the therapeutic border. You will also learn how to recognize when you have crossed a border and develop strategies for getting yourself back on track.
Because we are most vulnerable to boundary crossings when we are not taking care of ourselves, or when we do not have a work/life balance, we also want to discuss self-care strategies. These strategies are important for any nurse but particularly oncology nurses because we need to prevent talented oncology nurses from burnout. The goal is to keep oncology nurses in oncology, where they can make the biggest impact.