3/4/2019

Challenges of 
Professional 
Boundaries in the 
Medical Setting
Cory Carlson, MSN RN
Nursing Supervisor, Inpatient
Behavioral Health

Objectives
Identify and review practices for
appropriate boundaries
between the professional and
the patient in relation to violent
situations in the dialysis setting

Disclosures

• No conflicts of interest to disclose

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Professional Boundaries
• Expectations set by the Board of Nursing and by
organizations to provide care and meet
patient’s needs

• Boundary violations are where the care

provider, “establishes a social, economic or
personal relationship with a patient.” (1)

• Any action where the benefit goes to the nurse,

not the patient’s care, is a boundary violation

Setting Boundaries
• What does the patient need right now?

• Do you know what you want?

o How is what I’m expecting making
me feel?
o What would I like to have happen
instead?
o What do I need to do to make what I
want happen? (1)

• Have a goal, know what you want,

expect the interaction to go well

Saying No
• You have the right and obligation to stay
professional and maintain a professional relationship
with the patient

• You don’t have to apologize, but do explain so the

patient does not feel the need to “save face”

• The type of request determines the response

• No vs I’m sorry, that is against my professional

boundaries

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Safety‐Assessing Risk
• What do we know about the patient?

o Risk factors
• Medical diagnosis: Psychosis, Post-
Truamatic Stress Disorder (PTSD), Substance
Use, Paranoia, Developmental Disorders,
Mania, Delirium, Hyponatremia
• Legal history
• Current presentation

STAMP
• Staring and eye contact
• Tone and Volume of voice
• Anxiety
• Mumbling
• Pacing

• The more STAMP cues you observe, the

greater the potential for violence (2)

Environmental Awareness
Recognizing that there is no
completely safe environment, our
goal is to:
• identify
• reduce
• prevent
• eliminate risk
(6)

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Personal Environment
• What can the person reach, obtain, or
have access to in other parts of the
facility?

• What can you use as a barrier?

• Last one in the room, first one out

De‐Escalation Mirror
• Monitor the tone and volume of your voice
o How we say it is more important than what we
say

• Be mindful of your body language

• Maintain personal space

• Role model the tone, volume and body language

you want from the person you are working with

De‐Escalation Skills
• Detachment: the art of staying professional,
thoughtful and in control of yourself during a
situation

• Empathy is attempting to respect and

understand the other person’s current situation,
reaction and emotions…thinking about why
they are reacting this way

• Being non-judgmental, professional and

compassionate

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De‐Escalation Strategies
• Acknowledgement: use empathy-”I would be

angry too if I could not control what was happening

to my body.”

• Apologize for the situation or anything that went

wrong: “I’m sorry you had to wait”

• Agreeing: find the small portion of what the person

is saying and agree with it if possible: “Few people

are happy when they are in pain.”

De‐Escalation Strategies
• Distress Tolerance
o Dialectical Behavioral Therapy technique
demonstrated to reduce symptoms (3)
o Distraction
• Pros and Cons

• Distraction/engage the other senses

o Music (headphones), TV, books, writing, move,
essential oils, food

• Pros and Cons

o Ask the person what these are, but control/frame
the question
• What will happen if you do/don’t do this?

Setting Limits
• Setting limits gives the individual control over
the situation, they determine what happens
next

• State the inappropriate behavior, positive

choice and consequence.

• If the behavior doesn’t change, then the

negative choice and consequence

• Limits must be reasonable and enforceable

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Setting Limits‐Examples
• Brian, your yelling is scaring me. Please calm
down so I can hear what you need and help
you.

• Person not calming—obtain help

• I need you to stop yelling, if you continue I am

going to leave you alone and give you a
chance to get control of your emotions

Real Life Situations….?
• Patient would like you to buy some of their
Etsy/candles/blankets? Son is selling raffle
tickets? Daughter is selling Girl Scout Cookies?

• Patient passes? Should you go to the funeral

service? Send a personal sympathy card?

• It is below zero and the patient cannot afford a

coat?

What If?
• A patient wants to friend you on social
media?

• A patient makes unwanted comments

about your appearance/makes you
uncomfortable?

• Patient asks you for money or food?

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Summary
• Knowing and maintaining professional boundaries can
help you act ethically and appropriately towards your
patients
• STAMP cues will help indicate the person’s level of risk
• Saying no may be difficult for people in a giving
profession, but is a necessary skill to help patients
succeed
• Check your de-escalation mirror, stay detached and use
empathy
• Try de-escalation strategies, including
acknowledgement, apologizing, agreeing, inviting
criticism and distress tolerance
• Set reasonable and enforceable limits if the situation
becomes dangerous or unprofessional

Questions?

References
• 1. National Council of the State Boards of Nursing.
(2011a). A nurse's guide to professional boundaries.
Retrieved from
• www.ncsbn.org/ProfessionalBoundaries_Complete.pdf
• 2. Vilhauer, J., PhD. (2015, December 18). How to Get
What You Really Want. Retrieved from
https://www.psychologytoday.com/us/blog/living-
forward/201512/how-get-what-you-really-want
• 3. J Adv Nurs. 2007 Jul;59(1):11-9. Epub 2007 Jun 3
(STAMP)
• 4. Slabbert, A., Hasking, P., & Boyes, M. (2018). Riding the
emotional roller coaster: The role of distress tolerance in
non-suicidal self-injury. Psychiatry Research, 269, 309-315.
doi:10.1016/j.psychres.2018.08.061