When nurses begin working in the home healthcare setting, especially in pediatrics, it can be difficult to maintain a strict professional relationship with the patient and their family. Home care nurses often become a valuable part of the family unit, and parents of pediatric patients and the children themselves can grow to view the nurse as a friend rather than a professional care provider. This can easily blur the boundaries between nurse and patient, and can complicate the professional work environment. The purpose of this article is to present four case studies that describe situations of boundary crossing in pediatric home care that could have been managed differently, and provide strategies for maintaining professional boundaries with patients and their families.
There is little research on the topic of professional boundaries in nursing, especially in the home healthcare setting. The most common subject matter related to nursing professional boundaries pertains to sexual boundaries (Griffith & Tengnah, 2013). However, accepting gifts from patients, connecting on social media, remaining in close contact with patients, and visiting patients after termination of employment are considered professional boundary violations as well (Benbow, 2013). Moreover, pediatric home care nurses who make decisions for their patients rather than encourage the parents be involved may also be violating professional boundaries (Hanna & Suplee, 2012).
Home healthcare is one of the fastest growing industries in the nation. According to the Bureau of Labor Statistics (2015), home care is projected to have a compound annual rate of change of 4.8% between 2014 and 2024. There are currently over 33,000 home healthcare agencies in the United States that employ more than 958,000 nurses, therapists, aides, and social workers to care for over 12 million patients (National Association for Home Care & Hospice, 2010). Approximately 122,673 pediatric patients aged 0 to 21 were discharged from acute care hospitals to home care in 2012 (Berry et al., 2016). Home healthcare allows children with specialized needs to normalize their lives by living in the home setting rather than in a hospital. Furthermore, home healthcare services are less expensive than hospital stays or living in skilled nursing facilities and can lead to better patient outcomes (Romagnoli et al., 2013).
Pediatric patients requiring home care commonly have congenital birth defects, neurological impediments, chronic respiratory illness, or difficulty feeding (Peacock & Kinney, 2015). The families of these patients can be overwhelmed with the additional care and equipment necessary to maintain the health of their child. Home healthcare professionals can help relieve their stress by managing patient equipment and medication, as well as educating families on proper skills and techniques to care for their child when healthcare professionals are not present.
Nursing Professional Boundaries
Nurses who work in the home healthcare setting should have a caring demeanor, exceptional communication skills, and outstanding time-management capabilities, and should be willing to participate in age-appropriate activities with the patient (Peacock & Kinney, 2015). These qualities found in home healthcare nurses usually lead to devoted relationships that can sometimes cross professional boundaries. Nursing professional boundaries are vital to the nurse–patient relationship and ensure that these relationships are based on trust and respect in order to preserve the patient's autonomy and dignity. It is the nurse's responsibility to maintain professional boundaries and act in a way that ensures that the patient's needs come first. The American Nurses Association (ANA) explains that nurses must have, “respect for the inherent dignity, worth, unique attributes, and human rights of all individuals” (2016, p. 1). Nurses must be nondiscriminatory, act in a manner that shows integrity, and act according to their own values without jeopardizing the dignity of themselves or others (ANA, 2015). To sustain these boundaries, the nurse must use critical thinking and discretionary judgment. Nurses should never act for personal gain, only for what is best for the patient.
Nurses should be cognizant of behaviors that suggest risk for crossing professional boundaries. Once a nurse allows a boundary to be crossed, it can be difficult to regain a professional relationship, and the situation could potentially harm the patient. Examples of red flag behaviors on the part of nurses include disclosing personal details about themselves, spending more time than is necessary with a patient, becoming “friends” on social media with patients, accepting gifts from patients, and flirting with patients (Griffith & Tengnah, 2013). Nurses may not always recognize when these boundary crossings occur, which can lead to more significant boundary crossings in the future (Holder & Schenthal, 2007).
Home Healthcare Nursing and Professional Boundaries
Home healthcare is a nursing specialty that requires competent nursing skills and critical thinking in decisive moments. The home healthcare setting requires unique autonomy that must be acquired with experience (Jarrín et al., 2014). Nurses typically work alone with their patients and families for 8 to 12 hours a day, multiple times a week, and do not have the support of on-site physicians or other healthcare providers. Nurses who work in the home setting have different relationships with their patients and patients' families than nurses who work in hospital settings. Therefore, professional boundaries are less defined in the home healthcare setting. Four case studies that demonstrate boundary crossing that threaten the integrity of the nurse–patient–family relationship are presented.
Case Study 1: Sexual Boundaries
Nurse Alexia was a 20-year-old newly licensed nurse working with her first patient in the home healthcare setting, a 17-year-old newly paraplegic male. She cared for him 4 days a week. On weekdays, the parents were typically not at home. On the weekends Nurse Alexia worked, she accompanied the family to many family events while she cared for and spent time with her patient. After several months, Nurse Alexia began sharing personal information about intimate details of her life. After 6 months of working together, the patient admitted his feelings for her. She told him she felt the same way and they agreed to wait until he was 18 years old to act on their shared feelings. Nurse Alexia terminated her professional relationship with her patient on his 18th birthday and immediately began an intimate relationship with him. The parents did not approve of this change in her relationship with their son and took legal action against Nurse Alexia. Although she had terminated her professional relationship with the patient prior to engaging intimately with him, Nurse Alexia was sanctioned by the nursing commission and was put on probation for 1 year.
Alexia was inexperienced and seemed to take advantage of her already vulnerable patient who likely felt isolated from his peers. He probably felt that someone was able to like him even with his disability and felt a sense of normalcy. Nurse Alexia most likely felt wanted and needed, which motivated her to pursue the inappropriate relationship.
- Educate patients on healthy nurse–patient relationships.
- Never further relationships with patients or act on any said feelings.
- Document and report the incident to your employer if patients reveal intimate feelings.
Case Study 2: Gift Boundaries
Nurse Caden began working for a Hispanic family in their home, caring for their 4-year-old son who had cerebral palsy. The mother of the family was a stay-at-home mom, whereas the father was frequently away at work. The mother loved to cook and enjoyed sharing her meals with friends and family. She always offered food to Nurse Caden and often made a place for him at the table without asking. Nurse Caden began to occasionally eat with the family and their friends for fear of being rude or disrespectful of the family's culture. The food was not intended as compensation, so Nurse Caden believed it was appropriate to accept. The mother began buying food from restaurants for Nurse Caden, even when he brought his own meal. He felt uncomfortable with the mother spending money on him and told her that it was not appropriate to purchase meals for him. However, she continued to do so. Nurse Caden felt obligated to eat the food after the mother had bought it for him for fear of being disrespectful. Nurse Caden gave up trying to convince the mother to stop buying him meals.
Nurse Caden was aware of his patient's Hispanic culture and that sharing meals was important to the family (Ohio State University, 2010); therefore, he accepted the meals. This opened the door for the mother to start buying Nurse Caden meals from restaurants. Although he attempted to discuss this with the mother and tell her it was inappropriate, he continued to eat the food. Therefore, the mother continued to purchase meals and a boundary was continuously crossed.
- Refuse all gifts including items, money, and food.
- Never accept gifts as compensation.
- Ask your employer to reinforce agency policies with the family.
Case Study 3: Communication Boundaries
Nurse Laura began working with an 18-month-old patient in the home care setting. The patient's mother and father were frequently out of the home and had requested to exchange phone numbers with Nurse Laura to get updates on their child throughout the day. Nurse Laura thought this was a good idea in case of an emergency. Initially, the parents called for updates on their child once or twice per day. The mother soon began contacting Nurse Laura just to chat or ask personal questions, even when Nurse Laura was not working. Nurse Laura did not want to be rude and was afraid to ignore phone calls in case it was an emergency call. Nurse Laura eventually moved and quit working with her patient. The mother of the patient continued to contact Nurse Laura and update her on the child. Nurse Laura finally ignored the phone calls and text messages from the mother.
Nurse Laura thought the circumstance of exchanging numbers with her patient's parents was appropriate. She never told the mother that it was inappropriate to call her when she was not working, which probably made the mother think it was acceptable. It was correct for Nurse Laura to stop answering calls from the mother, but this could have been managed differently so as not to leave the mother wondering what caused Nurse Laura to ignore her.
- Ask your employer how communication with the parents should be handled if there is not a landline telephone in the home.
- Explain to the patient's family that nurses cannot talk to them outside of working hours.
- Ask your employer to facilitate a conversation about agency policies.
- Ignore phone calls/texts outside of working hours and after termination of professional relationship.
Case Study 4: Social Media Boundaries
Nurse Kenton was working with his 9-year-old patient and her family for 10 months when his patient's parents asked him to “like” a page dedicated to their child on social media. The page focused on the patient's medical condition and occasionally posted pictures of the patient. Nurse Kenton believed that he was not “friending” the parents' or patient's personal accounts so it would be okay to show his support by “liking” the public page. When Nurse Kenton viewed the social media page though, he began to educate the viewers of the page on the patient's condition and what the patient had to endure each day. The parents were upset that Nurse Kenton violated their privacy and publically posted personal information about the patient's daily routine for all to see. They confronted Nurse Kenton who immediately deleted the post. The parents then reported the incident to the home healthcare agency and Nurse Kenton was terminated.
Nurse Kenton probably thought “liking” a public page on social media was appropriate because he was not adding the personal accounts of his patient or patient's family. Nurse Kenton likely did not think about privacy violations before posting about his patient on social media. Although he deleted his post after being confronted by the parents, nothing is permanently deleted online, and people who viewed the public page had the opportunity to see the information posted by Nurse Kenton before he deleted it.
- Explain to parents that you can't associate with them on social media sites due to agency policy.
- Decline invitations to be “friends” on social media by any patient or members of their family.
- Set your social media sites to “private” so that only those you approve have access to view what is on your social media sites.
- Never post patient names or identifiers on social media pages.
Maintaining professional nursing boundaries may seem obvious in some respects, such as avoiding romantic involvement with a patient. Others may be more ambiguous and nurses may not recognize when they are violating professional boundaries. Professional boundary violations are often unintentional. Therefore, it is important that nurses understand what is considered a professional boundary violation. Nurses must utilize as many resources as possible to educate themselves on professional nursing boundaries. Properly educated home care nurses can prevent psychological and emotional harm to their patient or patient's family by understanding and following the above suggestions for maintaining professional nursing boundaries. Nurses must be aware of their limitations and know when to ask for help from colleagues, their employer, or professional nursing organizations.
Employers can take steps to assist home healthcare nurses to maintain professional relationships by providing clear policies during the orientation period and thereafter. Employers should also provide families with information to understand the role of a nurse or other professional care provider in their home. All policies should be shared with both nurses and patients. In addition to employer policies and training, nurses must seek other avenues for continuing education, such as attending conferences and online webinars and subscribing to professional journals that target home healthcare nurses. Nurses should join a nursing professional organization that can connect nurses to webinars, conferences, and literature.
Nursing in the home is vastly different than in the acute care setting. Behavioral skills and communication methods necessary for home care nursing are not typically taught in nursing school. Home care nurses should educate themselves further on their specialty and provide input for future nursing research to help identify and prevent boundary crossing. If all these considerations are implemented, it is possible to reduce the occurrence of professional nursing boundary violations.
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