Journal of Pediatric Oncology

Nursing
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Exploring Boundaries in Pediatric Oncology Nursing

Heather N. Hartlage
Journal of Pediatric Oncology Nursing 2012 29: 109
DOI: 10.1177/1043454212438965
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438965

artlageJournal of Pediatric Oncology Nursing

JoPon29210.1177/1043454212438965H

Exploring Boundaries in Pediatric

Oncology Nursing

Journal of Pediatric Oncology Nursing

29(2) 109112
2012 by Association of Pediatric
Hematology/Oncology Nurses
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1043454212438965
http://jopon.sagepub.com

Heather N. Hartlage, BSN, RN, CPON1

Abstract
Professional patient boundaries are an issue that is relevant across all realms of nursing practice. By nature, nurses are
caring individuals.Therapeutic relationships are integral to the care of patients.When caring for patients on a daily basis
for extended periods of time, it can be difficult for nurses to know when their care goes beyond professional boundaries.
Providing care to patients in a pediatric oncology situation substantially increases this ethical dilemma. Length of stay,
degree of crisis, embedded relationships, and emotional turmoil, along with the nurturing connection between adult and
child, are among the reasons that boundaries are often blurred within the context of this sensitive patient population.
This article explores the differences between nursing care, boundary crossings, and boundary violations. Strategies
to evaluate nursing actions for appropriateness, along with reflection and development of individual boundaries, are
offered. The information presented is relevant not only to nursing care of pediatric patients who are facing chronic or
life-threatening conditions but also to each nurseclient relationship established in nursing practice.
Keywords
boundaries, therapeutic relationship, pediatric oncology, ethical dilemma

Therapeutic nurseclient relationships are the basis of nursing. When a therapeutic environment and relationship are
achieved, patient goals are met with efficiency and caring.
Caring behaviors that go beyond intravenous lines, medications, and painful medical procedures and address individual patients unique qualities are what distinguish the
nursing role from other health care team members (Cantrell
& Matula, 2009). Nurses are expected to act with benevolence (Peternelj-Taylor & Younge, 2003). Oftentimes, the
right thing to do is not clear-cut. Not every situation is the
same, nor does each client require an equal amount of psychosocial care and attention. For these reasons, professional
boundaries cannot be written as a definitive set of rules.
Personal reflection of boundaries is necessary to maintain
ethical delivery of care and yield positive patient
outcomes.

be blurred, nurses must keep the overall goal of professional vs social interactions with patients and families in
mind. Health care professionals must be cautious about
becoming overinvolved in relationships with patients and
families.
Personal needs of the nurse should be secondary in the
nursepatient relationship. Boundaries have been crossed
when personal needs take precedence over family/patient
needs. The NCSBN (2011) further clarifies this topic by
defining boundary violations as confusion between the
needs of the nurse and those of the patient (p. 4).
Examples of boundary violations are excessive personal
disclosure by the nurse, reversal of roles, assuming a role
other than that of the nurse, ie: as a friend, sexual misconduct, or any action that meets the needs of the nurse over
those of the patient/family.

Boundary Crossings Versus

Boundary Violations
The National Council of State Boards of Nursing
(NCSBN; 2011) defines boundary crossings as brief
excursions across professional lines of behavior that may
be inadvertent, thoughtless or even purposeful, while
attempting to meet a special therapeutic need of the
patient (p. 4). To lessen the chance that boundaries will

Indiana Wesleyan University, Louisville, KY, USA

Corresponding Author:
Heather N. Hartlage, BSN, RN, CPON, 4120 Wallingford Lane,
Louisville, KY 40218, USA
Email: heatherhartlage@insightbb.com

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Journal of Pediatric Oncology Nursing 29(2)

Quality Nursing Care

The ability to differentiate nursing care and therapeutic
relationships from boundary crossings is essential in
ensuring that boundary violations are not encountered.
Nursing care is a professional relationship between the
client and the nurse. Client needs should be clearly identified, and professional nursing interventions should be
geared toward meeting those needs. According to PeterneljTaylor and Younge (2003), professional relationships
involve the use of expert nursing knowledge to formulate
goals that meet the needs of the client. Goals should be
mutually developed between the patient, the family, and
the nursing staff. Professional standards of practice and
nursing codes of ethics help guide nurses in their actions.
The nature of nursing care involves the act of touch.
When nurses are performing care and providing comfort
for the patient and family, it is likely that some form of
touch will be involved. Nurses must be mindful of the
intent of touch and the appropriateness of this action in
relation to timing and context. It must be acknowledged
that not everyone wants to be touched, and for some, any
form of touch has sexual connotations (Playfair, 2010).
Although some may misconstrue the intent, the importance of this in a therapeutic relationship and in displaying
empathy is integral to quality nursing care. Nurses must
be comfortable with the act of touch and ensure that positive patient outcomes are at the forefront of the action.

Pediatric Nursing
Certain health care situations such as child abuse or
neglect, the terminal child, and mental health clients predispose the nurse to becoming overinvolved. In these
circumstances, boundaries are complicated, specifically
concerning the role of the nurse.
The pediatric population is one that requires special
attention to meet the needs of the patient and the family
unit. Age-appropriate challenges will be faced throughout
the growth and development of a child. One of the many
goals of nursing is to foster development in the patient
and facilitate achievement of developmental goals.
Health care professionals must recognize the importance
that peers play in the lives of patients. These relationships
cannot be replaced with those of adults (Ritchie, 2001).
Encouraging contact with peers via phone calls, letters,
and, most important, visitation enables the patient to
remain connected with friends. This interaction yields
age-appropriate achievement of developmental goals and
also decreases the risk of boundary violations.

Pediatric Oncology Nursing

The NCSBN (2011) specifically cautions against personal relationships with patients who may have an extended

need for nursing care. Oncology patients meet this criterion

of concern. The hospital and nursing unit become a second
home to the patients and families during treatment of their
malignancy. Hospitalizations for chemotherapy, infections,
procedures, and diagnostic studies become day-to-day proceedings for patients and families. The average inpatient
hospital stay for a child with acute myeloid leukemia is
approximately 6 months (Hawes, 2005). Due to the nature
of pediatric oncology nursing, close relationships often
develop with patients and families, making it challenging
to provide psychosocial care in the most effective
manner.
Fostering therapeutic relationships is key when working with the pediatric population. When adding malignancies to the clinical picture, the need for an effective
nursepatient relationship is paramount. When a child is
diagnosed with a malignancy, the entire family unit experiences crisis. This intensifies the need for a strong support system. Psychosocial care of both the patient and the
family must be addressed by the nursing professional, for
example enabling them to be active participants in their
care. Embedded relationships with pediatric patients and
their families increase the risk for boundary crossings or
violations.

Effects of Boundary Crossings and

Violations
Crossing boundaries can have detrimental effects on the
nursing unit as a whole. When a patient realizes that not
all nurses provide care in exactly the same way, it can
make it difficult for other staff members who will care
for this patient. One particular nurse cannot be available
to care for the child 24 hours a day (Hawes, 2005). For
example, Central line dressing changes are a routine part
of care for the oncology patient. When a patient becomes
so dependent on a staff member that he/she does not
allow another nurse to perform the task, this creates problems for quality nursing care. This results in not only
negative outcomes for the patient but also can create tension in the entire nursing unit.
It is a reality that when multiple families experience
similar crisis in their lives and spend a great deal of time
together in the hospital, they will talk among themselves.
Common places such as the playroom, family room,
lobby, or cafeteria serve as an outlet for parents who have
limited social involvement because of their childs illness
and restrictions. Discussion of treatment, prognosis,
struggles, and emotions will likely ensue. As families discuss nursing and care, they may feel as if they are not as
important as others because they do not have the same
bond with the staff that other families have developed.
This could potentially have a negative impact on patient
care. Those families may feel as if they are not being
treated as an equal and that they are not cared for in the

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Hartlage
same manner as others. It is never appropriate to make
anyone feel unequal. The degree of emotional turmoil in
their lives does not warrant the added stress of not being
the favorite patient or family.

Setting Individual Professional

Boundaries
As nurses set their individual professional boundaries,
they must not be so vague that they leave room for overinvolvement, nor so firm that nurses are unable to develop
necessary therapeutic relationships with patients and
families. The Rainbow Therapeutic Relations DecisionMaking Framework is designed to assist nurses deliberating between courses of action that may affect the nature
of the therapeutic relationship (Ashenberg, Dull, Lambert,
& McAliley, 1996). This framework uses a utilitarian
approach. Utilitarianism analyzes possible results and
picks the one that produces the most benefit over the
greatest scope (Kidder, 2009). It is suggested that any
patient interaction has the potential to produce both positive and negative outcomes. Individuals or groups must
strive to produce the greatest balance of positive outcomes
over negative ones, considering all persons, and over
time. Five contexts are presented in which the nurse must
evaluate his/her actions. These contexts include institutional philosophy and policies; patient and family goals;
needs, interests, and rights of patients, families, or
coworkers; level of nursepatient relationship; and the
nurses personal philosophy and values (Ashenberg et al,
1996). This evaluation process enables the nurse to determine if his or her actions will facilitate or hinder a therapeutic relationship. At this point, the nurse may decide to
continue, decline, or alter the intervention in a way that
avoids potential risk.
The concept behind The Rainbow Therapeutic Relations
Decision-Making Framework is one of ends-based thinking. Kidder (2009) describes this ethical thinking as one
that produces the greatest good for the greatest number.
This end justifies the means approach to ethical decision
making is applicable to the evaluation of nursepatient
relationships because it enables the nurse to make decisions regarding actions depending on the outcome of the
intervention. Assessing consequences and predicting outcomes guides nursing actions when using this framework.
When outcomes have the needs of the nurse at the forefront, or if consequences are expected to cross professional boundaries, actions should be modified.
When boundaries are crossed and the nurse has recognized this violation, it is important to reflect on the experience. Reflection on the events that led to the situation,
feelings that were involved, and actions that were inappropriate should be explored. Taking these reflections and
making conscious individual goals and guidelines to

prevent future boundary crossings is a way for the nurse

to grow from the incident. If the nurse has failed to recognize the boundary crossing, it is not likely that this will
result in a learning experience. Others may still be able to
learn from the event through reflection of how they perceive the event negatively affected patient goals and outcomes. Personal reflection based on knowledge, feelings,
experiences, and client situation should serve as an individual guide to nursing care and boundaries.

Preventing Boundary Crossings

and Violations
Preventing boundary crossings must be at the forefront of
each health care professionals mind. Adopting a proactive,
rather than a reactive, approach to establishing and maintaining boundaries is a crucial component of a therapeutic
relationship and providing quality patient care (PeterneljTaylor & Younge, 2003). Suggestions for a proactive
approach include self-awareness and self-monitoring, peer
debriefing, clinical supervision, and education. When performing interventions, the question that one should always
ask themselves is Whose needs are being met?
Nursing educators must recognize the importance of
integrating information about professional boundaries
into their curricula. Resources should be provided to both
students and nursing peers regarding setting appropriate
boundaries, warning signs of boundary violations, how to
assess boundaries, and how to react when boundaries
have been crossed. Providing education on this ethical
dilemma can increase individual awareness, and in turn,
may decrease the likelihood of occurrence.

Conclusion
Caring for and developing a special bond with patients
and families in the pediatric oncology setting is likely to
be meaningful for all parties involved. This experience
can be very rewarding. The special relationship between
the nurse and the pediatric patient may be the reason
why a nurse has chosen this specialty. Although this
relationship has its benefits, nurses must be aware of
professional boundaries and how their actions may be
construed by the patient, the family, and other health
care professionals. When boundaries are crossed, patient
care suffers. Other families as well as coworkers on the
unit may be negatively affected by boundary crossings.
Personal reflection and identification of appropriate boundaries are necessary for each nurse to explore on an individual basis. Ensuring patient and family needs and
needs and goals of treatment remain the focus of care
can produce positive patient outcomes and more effective therapeutic relationships between the nurse, the
client, and the family unit.

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Journal of Pediatric Oncology Nursing 29(2)

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.

References
Ashenberg, M. D., Dull, S. M., Lambert, S. A., & McAliley, L. G.
(1996). Therapeutic relations decision making: The rainbow
framework. Pediatric Nursing, 22, 199-205.
Cantrell, M., & Matula, C. (2009). The meaning of comfort for
pediatric patients with cancer. Oncology Nursing Forum,
36, 303-309.
Hawes, R. (2005). Therapeutic relationships with children and
families. Pediatric Nursing, 17(6), 15-18.
Kidder, R. M. (2009). Overview: The ethics of right versus right.
In How good people make tough choices: Resolving the
dilemmas of ethical living (2nd ed., pp. 13-30). Retrieved
from http://www.globalethics.org/resources/Chapter-1

-How-Good-People-Make-Tough-Choices-by-RushworthM-Kidder/28/
National Council of State Boards of Nursing. (2011). A nurses
guide to professional boundaries. Retrieved from https://
www.ncsbn.org/ProfessionalBoundaries_Complete.pdf
Peternelj-Taylor, C. A., & Yonge, O. (2003). Exploring boundaries in the nurse-client relationship: Professional roles and
responsibilities. Perspectives in Psychiatric Care, 39, 55-66.
Playfair, C. (2010). Human relationships: An exploration of loneliness and touch. British Journal of Nursing, 19, 122-126.
Ritchie, M. (2001). Psychosocial nursing care for adolescents
with cancer. Issues in Comprehensive Pediatric Nursing,
24, 165-175.

Bio
Heather N. Hartlage, BSN, RN, CPON, has a Bachelor of
Science in Nursing degree from Spalding University and has
experience as a staff nurse in oncology and nephrology. She
is currently employed as a full-time nursing instructor at
Spencerian College and is presently enrolled in a Masters of
Science in Nursing Education program at Indiana Wesleyan
University.

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