As a professional helping relationship, the relationship between the nurse and client or service user is characterized by a code of practice and bound- aries (NMC, 2008). A healthy helping relationship is based on trust, which comprises openness and mutual respect. Boundaries define the limits of be- haviour between nurse and client. Their function is to protect the client and the nurse. Using the metaphor of a picture, boundaries have been compared to the ‘frame’ of a picture (Gray, 1994). Therefore, in mental health nursing, the function of boundaries is to contain the client by maintaining the boundary of the clinical work, which in turn can have a positive therapeutic outcome.
For example, imagine you are being allocated to a new placement. Allocations have informed you which placement you have been allocated, when you will commence the placement and for how long. You are also informed to contact the unit to find out your shifts. When you phone the ward, the staff nurse is aware of your starting date and informs you of your shifts. As a student mental health nurse, this is a common occurrence throughout your nurse education, which for the most part runs smoothly. Becoming familiar with such prac- tices and, more importantly, the consistency of such practices helps you to feel contained emotionally, conveys a sense of being cared for and allows you to focus on other aspects of your learning, all of which contributes to your ongoing professional and personal learning and development as a mental health nurse.
Now imagine, how you might feel if:
r your name were not on the change of placement list
r you were not informed until the last minute when you were starting and ending your placement
r the ward staff were not expecting you when you arrived on the ward for your placement.
How might you feel? What might you be thinking?
Now imagine how a similar experience might occur in clinical practice in- volving a client.
The intention of this exercise is to highlight to you the importance of bound- aries and their therapeutic value. As a mental health nurse, it is important that you understand and work with boundaries.
Setting boundaries
Setting boundaries at the outset of the therapeutic relationship is important for the client and nurse so that both can make decisions about what is and what is not permitted in the helping relationship. Best practice requires that there should be an explicit verbal working agreement between the nurse and the client from the beginning. While the details of each agreement may vary, clarification and agreement of the requirements, expectations and responsibil- ities are likely to include the following important issues, as illustrated in the examples below.
r Confidentiality and the limits of confidentiality. As a mental health nurse you must respect clients’ right to confidentiality and en- sure that they are aware of how and why information is shared with those who are providing care. For example, you might reassure a client who is concerned that information concerning his mental health will be disclosed to his family by saying: ‘Whatever you say to me will be confidential, that means no information will be shared with your fam- ily or anyone else without your consent. However, as you know, I am a member of the MDT and in order for the team to work effectively and for the welfare of clients, we share information about clients with one another. So I will have to tell the team about your suicidal thoughts.’
r Refusing gifts, favours or hospitality that might be inter- preted as an attempt to gain preferential treatment. For ex- ample, a client’s relative might want to express her appreciation for the care delivered to her elderly father by inviting you to his 90th birth- day party. Whilst very appreciative and flattered to be offered such an invitation, you think about it and decide that it is best to decline the offer by saying: ‘Thank you so much for your invitation to your father’s
party. It is very kind of you but I am sorry I am unable to attend. I hope your father and your family have a great celebration.’
r Maintaining clear sexual boundaries at all times with people in your care, their families and carers. For example, a client whom you have known for several weeks and with whom you have developed a good therapeutic relationship says to you: ‘I am being discharged next week. I was wondering if you would like to come out for a drink with me. I just want to say thank you to you.’ In response, you might say,
‘Thank you for your invitation but I am sorry I cannot meet you for a drink when you are discharged.’
Other issues relating to boundaries may include the following.
r Time boundaries, for example you might negotiate the time boundaries by saying, ‘I know that you attend the anxiety management group every Wednesday. I can see you after that, at 4pm until 4.30pm. Does this time suit you?’
r Cancellations of meetings, for example the nurse might say to the service user, ‘If you are unable to attend can you please phone me as soon as possible? Also have you got a phone number to contact you if I have to cancel our appointment?’
Sometimes clients may disregard or challenge professional boundaries, ei- ther consciously or unconsciously and for many reasons relating to the client’s past experiences. It is important that the mental health nurse tries to un- derstand the purpose of the client’s behaviour. What is she or he trying to communicate? Working with clients who disregard or challenge professional boundaries can be challenging and the mental health nurse may not know how best to respond. The following are examples of responses that nurses might make to clients in their attempt to restore the boundaries needed.
Maintaining boundaries
Responding to boundary infringements
Boundary infringement Possible responses Being asked personal
questions that you feel uncomfortable answering, for example:
Politely ignore the question and carry on the conversation.
‘I am wondering what has prompted you to ask that question.’
(continued)
Boundary infringement Possible responses Sexualized questions, ‘Have
you ever been sexually abused?’ ‘Are you gay?’
Personal questions, ‘Where do you live?’
‘How much do you earn?’
‘I can see what has prompted you to ask me that question, but this conversation is about you.’
‘That is too personal to answer.’
‘I need to think about that. I will come back to you later about it.’
‘I don’t think talking about my experiences is going to be useful to you.’
It is important to be mindful of your tone and body language, for example tone of voice, facial expression.
Sometimes letting the client know that you are aware of what s/he is doing, and why they might be doing it. For example, saying the following gently and tentatively may discourage the client from repeating their behaviour: ‘I wonder if you are asking me these questions to see whether I will get embarrassed and feel uncomfortable?’
Invading the nurse’s personal space, standing too close or physically touching the nurse.
‘I would appreciate it if you would stand further back when you speak to me.’
‘Please do not touch my arm.’
‘I want to continue our conversation, but I cannot listen to you if you continue to shout at me.’
Challenging time
boundaries, for example always turning up late, going over time by disclosing important information or asking questions at the end of the session.
‘I am sorry but we need to end now. I would like you to bring this up next week.’
‘It is important that we start and end at the agreed time.’
‘I have noticed that you tend to ask important questions at the end of the session. I wonder if you want to ask any questions now so that I have plenty of time to answer them.’
The above responses are by no means exhaustive or intended to be pre- scriptive. We strongly recommend that you practise these responses with your colleagues and mentor, and more importantly reflect on your ability to use such responses, while identifying your strengths and areas for further development.
Having considered the importance of setting and maintaining boundaries in a professional helping relationship and showing you how to demonstrate these in your work, we now move on to the discussing the attributes of effective helpers.