Establishing and Maintaining Professional Boundaries

While work can have a positive impact on mental health by providing opportunities for inclusiveness and a sense of purpose and achievement, toxic (or unsafe) working environments can, in turn, negatively affect employees’ mental health (World Health Organization [WHO], 2024).

Toxic working environments can involve (WHO, 2024):

• Incivility/bullying
• Discrimination and exclusion (age, ethnicity/race, religion, disability, gender/sexual orientation)
• Unsafe and excessive workloads (i.e., high patient care loads, lengthy overtime)
• Unsafe/poor physical working conditions

Safe working environments provide HCPs with what they need to provide care/services to patients safely and ultimately improve staff retention, work performance, and productivity (WHO, 2024). Setting boundaries by speaking up when injustices are observed/experienced or when assigned an unsafe workload can contribute to safe working environments.

Social media use in healthcare is fairly controversial as platforms are typically viewed publicly. It’s well-known that HCPs must keep patients’ medical information private according to the Health Insurance Portability and Accountability Act of 1996 (HIPPA). Protecting patients’ information is setting boundaries with your behavior to maintain a trusting relationship with the patient. However, something as simple as tattoos can easily identify a patient on a social media page should an HCP post a patient’s photo (Hennessy et al., 2023).

Privacy breaches, such as snapping a photo with a patient, may seem innocent. Still, without the patient’s consent, this action can lead to disciplinary actions with licensing boards, legal consequences, and media coverage (NCSBN, 2024b). Some organizations may even prohibit the action entirely. A general rule is to obtain the patient’s consent beforehand. When obtaining consent, the HCP should explain how they intend to use the photo and why they are posting it (Hennessy et al., 2023). Most importantly, HCPs should follow the organization’s policy regarding social media use.

To maintain professionalism in healthcare, HCPs must refrain from inappropriate relationships in the workplace. HCPs can have inappropriate relationships with patients, family members, visitors, and colleagues. Inappropriate relationships involve an inappropriate exchange and can be financial, emotional, or sexual in nature (Health and Care Professionals Council [HCPC], 2024).

Examples include (NCSBN, 2024a; HCPC, 2024):

• Giving or receiving gifts or money
• Invitations to connect socially (on the phone, in person, or online)
• Engaging in friendships (romantic or platonic) or sexual relationships
• Keeping secrets with a patient (or for a patient)
• Talking negatively about the workplace/colleagues with patients

Some of these behaviors/relationships may be consensual but still considered inappropriate in the workplace, particularly those between HCPs and patients. Beginning a sexual relationship with a current or former patient is considered inappropriate, even if initiated by the patient (NCSBN, 2024a). Something as simple as spending more time than usual with a patient can also be considered inappropriate (NCSBN, 2024a). HCPs should refer to their workplace’s policy for a list of inappropriate relationships to avoid.

Employees tend to engage in friendly banter with one another while at work. While these interactions are not necessarily inappropriate, topics discussed during these interactions may be unintentionally inappropriate. Casual discussions about a colleague’s sex life or self-disclosure about one’s own sex life may be considered a form of sexual misconduct (HCPC, 2024). Even offering compliments about a patient’s or coworker’s physical appearance may be perceived as sexual misconduct.

Sexual misconduct – unwanted sexual behaviors – is an extreme form of unacceptable behavior that can be criminal(HCPC, 2024). A primary characteristic of sexual misconduct is the victim’s perception that the behavior is inappropriate (NCSBN, 2024a). Behaviors include seduction, harassment, touching, sharing sexually explicit images/videos, making sexual remarks, violence, and abuse (HCPC, 2024).

If an HCP is sexually inappropriate with a patient, the patient may fear speaking up due to the power imbalance (AbuDagga et al., 2019). HCPs aware of the situation may hesitate to report the offending individual due to legal ramifications (AbuDagga et al., 2019). The effects of sexual misconduct can be long-lasting and include physical, mental, and emotional harm (HCPC, 2024).

The offending individual must know their behavior is unacceptable, offensive, or inappropriate. Communication must be clear and direct so the individual understands the wrong behavior. This may include explaining how the behavior is offensive and how others may interpret it. An organization often performs this step through workplace policy and training.

Sometimes, an individual may unknowingly behave offensively (NCSBN, 2024a). These personal offenses may not be clearly defined in an organization’s policy or code of conduct. For example, it is well-known that addressing a physician by their first name is considered disrespectful. The healthcare industry has culturally established this action as disrespectful (unless the physician prefers to be addressed this way). However, a personal boundary must be set when behaviors have not been formally established as offensive.

For example, an HCP may call a colleague a nickname that is generally not considered offensive, such as “Robbie” instead of their full name, “Robert.” However, suppose Robert feels the nickname is disrespectful (for example, based on cultural beliefs) and prefers to be called by their full first name. In that case, they must communicate this preference to their colleague.

The HCP should make it clear to the patient/family or colleague that a behavior should stop. This is key in establishing boundaries. This action may require support from a supervisor (NCSBN, 2024a). Supervisors can explain to the offending individual any negative consequences of the behavior, such as limited warnings, potential suspension or termination of employment, or involvement of law enforcement (NCSBN, 2024b).

After establishing the boundary, the offending individual should know what action is acceptable (or how healthy professional relationships should function). People are different, and what may be offensive to some may not be offensive to others. Culture influences behavior and beliefs (Bentahila et al., 2021). This includes behaviors/beliefs that others may find offensive. For this reason, explaining acceptable behavior gives individuals a guide to follow, which ensures both parties feel respected in the professional relationship. An organization also performs this step through workplace policy and training.

Maintaining boundaries is simply reinstating the same boundary repeatedly while identifying and addressing any boundary violations (NCSBN, 2024a). HCPs can maintain boundaries by adhering to codes of conduct or workplace policies, reporting inappropriate behaviors, and following the chain of command rather than staying silent (even if the offending individual is a supervisor).

Moral distress is knowing the right thing to do but feeling constrained due to the conflicting beliefs of others or the organization (Christman et al., 2022). If an HCP fears backlash from the offending individual, colleagues, or the organization, they may hesitate to speak up or report the unacceptable behavior.

Moral courage, the ability to speak up for what is right regardless of the consequences (Christman et al., 2022), can help HCPs manage morally distressing situations in which they must set boundaries. Administrators and leaders have a responsibility to cultivate environments in which HCPs feel comfortable speaking up without fear of retaliation or intimidation.

An HCP’s ability to set boundaries in the workplace may also be influenced by an inability to set boundaries in their personal lives. HCPs who struggle with personal boundary-setting may benefit from personal development training to address potential barriers. However, even when facing personal struggles, workplace codes of conduct and policies provide HCPs with clear guidance on unacceptable behaviors to report and when to report them.

Think back on the home trespasser example from earlier. After the homeowner has exhausted all efforts to keep the trespasser away, they enlist the help of law enforcement. When an unacceptable action is repeated in the healthcare setting, HCPs follow chains of command, notifying supervisors and making formal reports as required by the organization’s policy. Some behaviors, like sexual misconduct, require immediate reporting after the first offense (NCSBN, 2024a).

Organization leaders have a responsibility to support HCPs and establish protocols on what to do should a patient, family member, or staff member continually cross a boundary.

What is happening here? Why might the HCP hesitate to report the incident?

• The HCP may be experiencing moral distress. Because the HCP’s supervisor is friends with the physician, the HCP may worry that the supervisor will be offended by the report and that the great working relationship they have with the supervisor may be lost. This fear of backlash can cause the HCP to struggle with setting appropriate boundaries.

Do you believe the physician’s remark is a form of sexual misconduct? What action should the HCP take?

• Remarks about an individual’s physical appearance may be considered sexual misconduct in some cases, but the primary takeaway is the HCP felt uncomfortable with the remark. For this reason, they should set a boundary by either addressing the physician directly or speaking with a supervisor. The organization’s policy should outline how to address situations such as these.

What action should the organization take that may benefit this situation?

• The organization should cultivate an environment where all employees feel comfortable reporting inappropriate or questionable behaviors. This type of environment can support the development of moral courage in employees, which can be used to tackle the moral distress they may feel when faced with morally challenging situations at work.

If the remark is listed as a form of sexual misconduct in the organization’s policy, the HCP is required to report the incident. If the HCP is unsure if the remark is considered sexual misconduct, they should discuss the incident with a supervisor. Because the HCP and physician were recently introduced to the sexual misconduct policy in the training session the day prior, all parties involved may be aware of the potential inappropriateness of the remark. However, making this determination is the responsibility of the supervisor. The HCP’s sole responsibility is to address the incident rather than ignore it.

By addressing the situation rather than remaining silent, the HCP increases the likelihood the uncomfortable behavior will cease. If the HCP does not speak up, the physician’s behavior may worsen, which can cause long-lasting mental and emotional harm to the HCP. Reporting the situation may cause backlash, as feared, but if so, the HCP should follow the organization’s chain of command until a resolution has been reached.