Maintaining Boundaries

The code: Standards of conduct, performance and ethics for nurses and midwives (2008) states

“You must treat people as individuals and respect their dignity”
“You must refuse and gifts, favours or hospitality that might be interpreted as an attempt to gain preferential treatment”
“You must not abuse your privileged position for your own ends”
“You must establish and actively maintain clear "sexual boundaries" at all times with people in your care, their families and carers.”

What do we mean by ‘boundaries’?

Boundaries define the limits of behaviour which allow a nurse or midwife to have a professional relationship with a person in their care. The relationship between a nurse or midwife and the person in their care is a professional relationship based on trust, respect and the appropriate use of power. The focus of the relationship is based on meeting the health needs of the person in their care. A nurse or a midwife crosses a professional boundary when they behave in any way that oversteps their professional role with a person in their care, their family member or any one else involved with the person's care to create a personal relationship. A sexual boundary has been breached when a nurse or midwife inappropriately uses words or actions of a sexual nature with a person in their care, members of the person's immediate family, or any one else involved with the person's care.

In professional relationships, an intimacy may develop as a result of the person in the care of a nurse or midwife sharing personal information, feelings and vulnerabilities. This should not be confused with a social intimacy and it is important to maintain a professional relationship and clear boundaries. Ideas about what is intimate or appropriate may differ across society and the nurse or midwife must treat people as individuals with sensitivity to, and respect for cultural and other differences. Cultural differences can affect individuals’ ideas about their personal boundaries. Nurses and midwives should therefore be sensitive to this and treat people in a way that reflects their views and wishes and preserves their dignity. For example, an individual may prefer to be cared for by a nurse or midwife of the same gender.

What do ‘words or actions of a sexual nature’ mean?

Words, acts or behaviour that are designed to arouse or gratify sexual impulses or desires are defined as sexualised behaviour (Council for Health Regulatory Excellence (CHRE 2009)). This includes any words, actions or behaviour that could reasonably be interpreted as sexually inappropriate or unprofessional. Breaches of sexual boundaries between a nurse or midwife and the person in their care, or any other person involved with the persons’ care, include:

Beginning a personal relationship during or after treatment
Engaging in sexual activity
Discussing sexual matters that are not relevant to treatment
Using sexual humour or telling “dirty jokes”
Repeatedly engaging in prolonged conversation about personal matters unrelated to treatment.

The CHRE document details a number of behaviours that, whilst they do not necessarily constitute a breach of sexual boundaries, may lead to displaying sexualised behaviour towards the people in your care, or carers. These include:

Revealing intimate details to a person in your care during a professional consultation
Giving or accepting social invitations where this is sexually motivated
Visiting a persons home unannounced and without a prior appointment
Seeing a person in your care outside of normal practice
Clinically unnecessary communications.

How does this harm the people in the care of a nurse or midwife?

The public expect to be able to trust nurses and midwives to provide care that is in their best interests and when boundaries are crossed that trust can be damaged. If the nurse or midwife falls short of the standards expected then they are acting unprofessionally and in some instances may be breaking the law (Sexual Offences Act 2003). A nurse or midwife breaching any sexual boundary exploits the person in their care and damages public trust. There are many reported harmful consequences to the people in the care of a nurse or midwife when sexual boundaries are breached. These can include emotional turmoil, shame, fear, rage, guilt, self-blame, identity confusion, sexual dysfunction, depression, self-harm, suicide.

How can nurses and midwives avoid breaching sexual boundaries?

Nurses and midwives should acknowledge that there is a potential power imbalance in the relationship between the nurse or midwife and the person in their care. CHRE (2009) identify potential reasons why the power imbalance may arise:

The person in their care may have to show personal information in order to be diagnosed and have treatment.
It is the healthcare professional who influences the level of intimacy or physical contact during the therapeutic and diagnostic processes.
The healthcare professional knows what it is that constitutes appropriateness associated with professional practice but the person in our care may be in an unfamiliar situation and may not know what is appropriate.

It is this power differential that results in patient vulnerability. The NMC believes that sexual relationships at any time with people in the care of a nurse or midwife, past or present, are always potentially abusive. Therefore, nurses and midwives must not engage in any sexual activity with any person in their care or make any sexual advances verbally, physically or by innuendo. In the event of a complaint it will be for the nurse or midwife to show that he or she has not abused or exploited any professional relationship.

It is not uncommon for a nurse or midwife to have sexual feelings towards a person in their care but acting on such feelings is always unprofessional and potentially damaging to the person the nurse or midwife is caring for.

To avoid any misunderstandings or inappropriate conduct the nurse or midwife should employ the following safeguards:

Keep to relevant personal detail in history taking
Provide adequate information and explanation which helps to avoid misunderstandings and misinterpretation
Honour confidentiality
Maintain proper appointment systems
Provide suitable facilities with screens for undressing
Offer the choice for the presence of a trained chaperone during intimate examinations or treatment
Be aware of what is culturally acceptable to individuals, especially those of a different race or religion
Never use sexually demeaning words or actions or dirty jokes
Refrain from undue familiarity
Be cautious of the context and intent if accepting a gift from a person in your care
Be aware that people may be vulnerable at times of crisis in their personal life
Get help early for personal crises
Do not involve the people in your care, or members of their immediate family, or any other person involved with their care in personal problems
Consult with colleagues about difficult situations

The professional judgement of the nurse or midwife may be impaired when boundaries are crossed or breached, resulting in the nurse or midwife losing objectivity regarding the care and treatment of the person. As a result the nurse or midwife may not be able to meet the requirements of the professional code to ‘make the care of people your first concern’. The NMC considers that the safest course of action would be to conclude that the nurse or midwife cannot continue to provide the correct level of care as it would be difficult to assure that they can remain objective. Therefore, nurses and midwives must:

Find alternative care for the person
Ensure a proper handover of care, where necessary
Ensure the person does not feel that they are in the wrong as a result of the handover of care to another nurse or midwife

What should a nurse or midwife do if a person in their care or their carer is attracted to them?

When a person in the care of a nurse or midwife displays sexualised behaviour towards them an appropriate course of action may be to discuss their feelings in a constructive manner and attempt to re-establish a professional relationship. If this is not possible, they should transfer the person’s care to another nurse or midwife. They should seek advice from a colleague or appropriate professional body in order to decide the most professional course of action to take. It is important that the person’s confidentiality is maintained in these circumstances.

What about people formerly in the care of a nurse or midwife?

A relationship with a person formerly in the care of a nurse or midwife, or their carer, will often be inappropriate for the same reasons that a relationship is inappropriate with a person currently in the care of a nurse or midwife. The relationship may be influenced by the previous professional relationship, which will often have involved an imbalance of power. Nurses or midwives who think that such a relationship may develop, must consider the possible future harm this may cause and the impact on their professional status. They must consider the following:

When the professional relationship ended and how long this relationship lasted
Whether the professional relationship consisted of a significant power imbalance
Whether the former person in their care, was or still is particularly vulnerable
Whether they are exploiting a power imbalance or the knowledge or influence that they gained through the professional relationship to develop or progress the relationship
Whether they are treating, or are likely to treat any other members of the person's family

In the event of a complaint it will be for the nurse or midwife to show that he or she has not abused or exploited any professional relationship. They will also need to show that all the issues above have been considered and that they have sought appropriate advice.

What if the nurse or midwife thinks someone else may be breaching boundaries?

The code: Standards of conduct, performance and ethics for nurses and midwives (2008) states “You must act without delay if you believe that you, a colleague or anyone else may be putting someone at risk”.

Nurses or midwives who become aware that another healthcare professional has, or may have, breached boundaries with a current or previous person in their care, or carer, must report this to a person of appropriate authority. They have a professional duty to take action to ensure the people in their care are protected and failure to take such action could amount to professional misconduct on their part. All incidents of alleged or suspected abuse require a thorough and careful investigation, which must take full account of the circumstances and the context of the abuse. Depending on the circumstances, the police may need to be alerted, as well as the regulatory body for the healthcare professional or the employer. The NMC recognizes the right of employers and managers to take appropriate local remedial or disciplinary action. However, the NMC must be informed of substantive allegations of professional misconduct made against named nurses or midwives, which if proven, would call into question their fitness to practise.

This information was updated in May 2012.