Council for Nurses and Midwives

Malta

Professional Boundaries for Nurses

and Midwives

JANUARY 2020

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GLOSSARY

Abuse: the misuse of power within the therapeutic relationship, betraying of the patient/client’s

trust, and violation of respect or professional relationship whereby such action results in

harming the patient/client.

Accountability: being responsible for one’s actions and decisions and accepting the

consequences.

Boundary: a point at which the nurse/midwife–patient/client relationship changes from a

therapeutic to a personal one.

Competence: the ability of the nurse or midwife to practise safely and effectively fulfilling

their professional responsibility within their scope of practice.

Dual Relationship: refers to any situation where multiple roles between the nurse/midwife and

a patient exists such as the patient is a family member or friend.

Empathy: intellectual and emotional awareness and understanding feelings and experiences and

to communicate that understanding to the patient/client.

Neglect: disregard or failure to perform a duty or to give due attention or care.

Patient: a person who uses health and social care services. In some instances the terms

‘client’, ‘mother’ and ‘individual’ are used in place of the term patient depending on

the context.

Power: the capacity to possess knowledge, to act or influence the behaviour or decisions of

others based upon education, authority, and privileges.

Professional Intimacy: the physical, psychological, emotional and/or spiritual elements that

create a sense of closeness within the therapeutic relationship.

Respect: due regards to the patient/client feelings, wishes and rights.

Therapeutic Relationship: refers to the relationship between a healthcare professional and a

client or/and his/her informal carers through which they engage with each other.

Trust: to become vulnerable and dependent on the other person's intentions and motivations.

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PREAMBLE

This document is designed to be read in conjunction with the Code of Ethics and Standards for

Professional Conduct for Nurses and Midwives (1)). It is intended to provide a more detailed

guidance on managing professional boundaries.

INTRODUCTION

Nurse/midwife-patient relationship should always be therapeutic and professional (1). This entails

that nurses and midwives must apply their professional competence towards meeting the identified

needs of the patients under their care. It is distinguished from any other relationship as it is both

focused and goal-oriented aiming for a beneficial outcome for the patient. Furthermore, once the

mutually agreed goals are met, the established therapeutic relationship is terminated. All

expectations are on the professional to ensure that the provision of care is effective, safe and

ethically correct.

An effective therapeutic relationship is based on mutual trust, respect, empathy, professional

intimacy and appropriate use of power (2). The patient must trust that nurses and midwives will

work for their best interest. It is also expected that the professionals treat them with respect as

autonomous individuals. Intrinsically, the provision of nursing and midwifery care involves a level of

physical, psychological and emotional intimacy. This level of intimacy in addition to the professional

access to personal information, knowledge and skills and authority within the healthcare system can

increase patients’ vulnerability resulting in unequal power within the nurse/midwife-patient

relationship.

Patient vulnerability and unequal power within the nurse-patient relationship place an obligation on

the professional to maintain professional boundaries. Boundary crossings may occur, at times

inadvertently or thoughtlessly and at other times purposefully. Nurses and midwives should do their

utmost not to cross the professional boundaries, as this compromises the therapeutic relationship.

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It must be kept in mind that the responsibility for establishing and maintaining the boundaries lies

with the nurse and midwife irrespective of the patient actions or expectations.

The scope of this document is to delineate the responsibilities of both nurses and midwives to

maintain such boundaries. These responsibilities are divided into those actions that help to nurture

and maintain the therapeutic relationship and those actions that result in boundary crossing.

TO NURTURE AND MAINTAIN A THERAPEUTIC RELATIONSHIP NURSES AND MIDWIVES

SHOULD:

1. Refrain from engaging in dual relationship as much as possible. If this is unavoidable, nurses

and midwives should be aware of the potential harm and take the necessary steps to

minimise the risks. Nurses and midwives always need to exercise confidentiality and make

it clear what can be expected of them when they are acting in their professional capacity.

2. Ensure that the judgement and objectivity is not undermined by co-existing relationships

during the nurse/midwife-patient relationship.

3. Seek support and guidance from colleagues when concerns relating to boundaries arise.

4. Plan care around meeting patient needs entrusted under their care and refrain from

meeting their personal needs in the relationship.

5. Help patients understand the limits of the therapeutic relationship especially when their

requests exceed this limit.

6. Understand the complexities of terminating the relationship.

7. Treat personal information obtained in a professional capacity as confidential. Nurses and

midwives must not use this information or their position to take advantage in any way.

8. Carefully consider their motives before disclosing personal information. This should only

take place if the disclosure is considered as having a therapeutic benefit to the patient.

Excessive self-disclosure may end up with the patient becoming upset about the

nurse/midwife situation which shifts the primary focus of the relationship.

9. Ensure that the treatment provided does not differ between patients. Avoiding a patient can

lead to neglect. Avoidance can result due to a number of reasons such as long

hospitalisation, exhibition of undesirable behaviour such as complaining all the times, and

aggressive tendencies. It is important that the nurse or midwife discuss their feelings with

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their colleagues and superiors and develop a plan of care that will promote patients’ needs

and well-being whilst also addressing the nurse/midwife’s concerns.

10. Take all necessary measures not to breach boundaries to minimise risk of boundary

crossing.

ACTIONS THAT MAY RESULT IN VIOLATION OF PROFESSIONAL BOUNDARIES INCLUDES:

1. Development of friendship, romantic or sexual relationship with patients. This also applies

for electronic and social media platforms.

2. Interfering with the patients’ personal relationships.

3. Becoming emotionally involved in a patient’s personal relationship.

4. Crossing boundaries with the patient’s family and friends.

5. Accepting gifts from patient/clients, their family and friends. Gifts may be accepted after

ensuring the following:

a. The gift is not solicited by the nurse/midwife;

b. Patient is mentally competent;

c. The intent and expectations in offering the gift is considered such as during

discharge as opposed to on admission;

d. The timing is appropriate such as during Christmas or festive season; and

e. They do not change the dynamics of the therapeutic relationship.

6. Giving a gift to the patient.

7. Borrowing or attempting to borrow money from a patient.

8. Use of the professional position to sell products or promote nurses/midwives’ personal

interests.

CONCLUSION

Nurses and midwives need to ensure that they work within their professional boundaries.

Boundary crossing may arise from the professional desire to help the patients under their care.

It is important that nurses and midwives acknowledge that they cannot provide all the care

themselves but must liaise with other health professionals or services in order to meet patient

needs. Also nurses and midwives must be reflective of their own practice and become aware of

any warning signs that may suggest over or under involvement in the provision of patient care.

The maintenance of professional boundaries by nurses and midwives is a demonstration of

accountability and responsibility for one’s practice as prescribed in the Code of Ethics and

Standards of Professional Conduct for Nurses and Midwives (1).

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REFERENCES.

1. Council for Nurses and Midwives - Malta. Code of Ethics and Standards of Professional Conduct

for Nurses and Midwives. 2020.

2. College of Registered Nurses of Nova Scotia. Professional Boundaries and the Nurse-Client

Relationship: Keeping it safe and Therapeutic. Halifax, Canada : s.n., October 31, 2017.