“That’s enough now”— professional boundaries fortify self-care

COVID-19 has significantly changed the health care landscape in Australia and globally. Stress has increased in an already stressed workforce. My observations and assessment of nurses and midwives working in the pandemic has reinforced the importance of professional boundaries, now more than ever.

Nurses and midwives give of ourselves every day we go to work and in many aspects of our life. We give of ourselves physically, psychologically, and emotionally. From assisting to bring new life into the world to ensuring comfort when dying, nurses and midwives have always been at the forefront of providing care to others.

Throughout the challenges of the COVID-19 pandemic nurses and midwives have been tested and pushed to the end of their endurance. Many colleagues are tired, exhausted, frustrated, angry and fed up. Yet still we go to work each day and provide care to people who need it, wherever they need it — hospitals and health services, aged care, in people’s homes or other care settings.

Nurses and midwives have given and given and given more of themselves over the last two years. Some colleagues have given their lives. Colleagues have died because they contracted COVID-19. Some colleagues have taken their own lives due to anxiety, fear, grief and trauma about the pandemic and their role within it.

At times like this good professional boundaries are essential to protect our health and wellbeing. I have spent many years to working with professionals to understand and promote health professional boundaries. I trust that the content that follows may in some way assist you — my colleagues — to take that time to breathe for you and breathe for your health and wellbeing.

“That's enough now” is a phrase I developed while supporting professionals to identify and address factors that led to their boundary transgressions. “That's enough taking work home”, “that's enough workplace bullying”, “that's enough working long hours”, “that's enough unpaid overtime”. That's enough now.

Student nurses who can develop an understanding and demonstration of professional boundaries in the early journey of their profession will benefit in the long term as those boundaries help them to sustain their wellbeing and decrease the risk of burnout and compassion fatigue. Professionals who attend boundary training with me always say: I wish I had known this as a student.

There are many reasons people choose to become nurses or midwives. Some have personal experience of being a patient and were inspired by the care they received. Some come from a long line of carers or healers and follow great grandparents, grandparents and parents into the profession because their seniors were their role models for positive contribution to the community. Some people saw nursing or midwifery as a stable path with steady income and career opportunities.

For myself, I wanted an opportunity to leave the village of my birth and find new experiences in the world. I have never regretted the decision to become a nurse. I have experienced so many opportunities, daily learnings with increased knowledge and skills in so any areas. I have developed many great friendships with colleagues over my 30+ year career. I have experienced defining moments, knowing: I made a difference for that patient, that family.

The feeling that you made a difference is rare in many professions, but common in caring professions. It is a great enticement to keep giving more and more. It is almost like an addiction. I give more, I feel good, so I will keep giving more. Like any addiction, chasing the rush you get from giving more can lead you further and further from what is good and healthy for yourself and your own wellbeing.

When I experienced burnout I learned that no organisation is worth dying for. I discovered that organisations that I had given much of myself to — because I really felt they needed me — managed without me when I was no longer there. There was always someone else to fill the role. I was wrong to think that only I could do the job.

According to the WHO, nurses and midwives account for nearly 50% of the global health workforce, and whatever reasons they had for joining the workforce, most nurses and midwives enjoy providing care and making a positive difference for the people they serve. That enjoyment for many has been tested to the extremes during COVID-19. Nurses and midwives have been asked to cancel holidays and return to work.

As a result of the work demands of the pandemic nurses and midwives are asked to spend longer hours at work. Before you accept that extra shift, ask yourself:

• Am I ok to work today?
• Am I too fatigued to do the job safely?
• What about me?
• What about my health and wellbeing?
• What about my family, my children, my parents, my friends?

It is important that you ask these questions. Asking them is not selfish. Rather, the questions may help you move you from a position where the care you provide requires you give to others at a potential cost to self to a position in which you to prioritise caring for self to be able to continue to provide care to others. In short, these questions are a key step in beginning to protect your professional boundaries.

What do I mean by professional boundaries? The most common definition in nursing and midwifery has been:

Professional boundaries allow a nurse and a person to engage safely and effectively in a therapeutic and/or professional relationship. Professional boundaries refers to the clear separation that should exist between professional conduct aimed at meeting the health needs of people, and behaviour which serves a nurse’s own personal views, feelings and relationships that are not relevant to the professional relationship. — NMBA Code of conduct for nurses 2018

The focus of professional boundaries in nursing and midwifery has historically been (as it needs to be) on professional/patient relationships. However, my work has demonstrated that we can use the language and concepts of professional boundaries to create enhanced collegially boundaries that will assist us individually and as professionals.

While you think about the definition of professional boundaries provided above, I invite you to consider power/vulnerability dynamics between colleagues. For example, Unit Manager/staff, older/younger, more experienced/novice, male/female, cultural majority/minority or new to country.

Consider who has the power and who is vulnerable in the decision-making process. For example, planning shifts, in performance appraisal interactions and in asking for more. Improved collegial boundaries enhance the professional relationship because they empower the individual nurse in a subordinate position of power to be mindful of their own wellbeing and say: “That’s enough now.”

In the long term, nurses and midwives who feel empowered to protect their personal and professional boundaries make fewer mistakes, experience less resentment, and minimise burnout, leading to decreased interpersonal tension in workplaces.

Through my work I have identified several key factors that lead to the transgression of boundaries.

They include (but are not restricted to):

• lack of knowledge and awareness about the nuances and complexities of professional boundaries,
• workplace stressors including workplace bullying,
• personal stressors from home that the professional brings to work with them, and
• difficulty establishing and maintaining boundaries for fear of offending, appearing disrespectful or having patients and or colleagues dislike them.

The professionals I see in my practise frequently express themes around the wish to care for, to give more and to be liked. When I point out that professional boundaries can help to keep the collegial relationship safe and is beneficial for that relationship, I often hear:

• “I did not want to upset the person by saying no,”
• “I would have felt guilty if I had not said yes to overtime,” or
• “If I didn’t do it, who would? I couldn’t let the team down.”

Identifying that you have had enough is only the first step. Once you have realised that you can give no more that shift, that day, that week, the next step is to respectfully and with great dignity and generosity reply to requests to give more: “Thank you for considering me, I am not able to assist this time”.

I know that it’s a lot easier to suggest that than it is to actually do it. This statement will not be comfortable for many colleagues. It is important that each individual develop a script (or series of scripts) that works for them.

The challenge for many to figure out how to develop their own professional authority so that they can make the statement without feeling guilty or anxious that it may been seen as a challenge. Professional boundary training can help us overcome that challenge.

The use of boundary scripts, body awareness and body positioning has been supported by consistent feedback from professionals who have completed professional boundary training with me. Colleagues report that the training they receive in integrated professional boundary strategies has helped them to experience better communication with colleagues. Perhaps more importantly, they go home at the end of the shift thinking “good job done” rather than worrying about what was not done.

Understanding why you find it difficult to maintain boundaries will help you to interrupt the cycle.

I have developed a model on influencing factors to boundary transgressions that individuals have found beneficial to understand their decision making and action at the time of a collegial transgression. The model has four levels that are in relationship with one another. I have conducted professional boundary training with hundreds of professionals and the model resonates with them.

The model is:

Level 1: Intrapsychic

Within self, one's own moral compass, values, systems and ingrained learning from childhood and scripts from family of origin.

Consider:

• Was it safe to establish and maintain boundaries as a child or was there punishment?
• Was it rude to refuse an invite or a request?
• Was there messaging that discouraged asserting boundaries? For example: How can you be disrespectful by saying no?

Level 2: Interpersonal

The relationship an individual has with another person or members of a team.

Consider:

• Conflicting relationships
• Fear of speaking up fear of saying no
• Fear of asking for clarification
• Residual anxiety or trauma — for some individuals the interpersonal dynamic with a colleague may trigger (consciously, generally unconsciously) a similar role discomfort / fear / anxiety from a previous relationship, perhaps from childhood.

Level 3: Organisational

Aspects of the workplace at an organisation-wide level

Consider:

• What is being role modelled in the organisation?
• Blurred boundaries? Clear boundaries?
• Are there clear policies and guidelines in place that can help staff develop professional authority to establish and maintain boundaries with colleagues?

Also consider:

• The sense of belonging, being accepted, wanting to be liked (these aspects trigger back to the intrapsychic level)
• Not wanting to be ostracised or scapegoated.

As humans we will do almost anything to remain part of the tribe, even at cost to self.

Level 4: Broader system

The broader system of health, education, training and role modelling received. Broader system also includes the historical messaging about nursing/midwifery that (in many ways) encourage us to keep giving no matter the cost to self.

One way to make sense of the model for yourself is to draw a diagram of the four levels. We’ve created a printable worksheet to help you out.

Download the worksheet 

You and the colleague you need to set a boundary with are in the middle of the diagram. Around you, describe the influencing factors that may challenge your wish to set boundaries. Include:

• intrapsychic messaging from childhood, nurse/midwife training and cultural role modelling
• comments from colleagues, friends, your family and your children
• comments from broader society, eg is it permissible for nurses/midwives to set boundaries for their own wellbeing?

Note in the diagram all the influencing factors that make it difficult to set a boundary. As you add to the diagram strategies will present to you.

Here’s an example of how you might fill out the diagram.

I finish this piece with four strategies that professionals have found useful following boundary training with me. We are all unique human beings, and we must find our own level of professional and personal boundary acceptability to enhance our wellbeing and relationships with colleagues.

Our duty of care to self is imperative. We cannot provide safe and quality care when we feel compromised physically, psychologically and emotionally. We cannot provide safe and quality care if we are not supported and cared for.

These boundary strategies may assist to breathe renewed life into YOU.

1. Value yourself

This sounds easy, but it’s hard to put into practice. Especially when there is a long history of professionally giving to others and seeing the difference you can make. Remember: Looking after yourself before looking after others is not selfish, but self-giving. Consider: “ Is this enough now?”

2. Practice the power of the pause

Envisage that request from a Unit Manager: “Can you stay behind? We are really short of staff today.”

Practice pausing before responding. Take a breath before responding. Unless the request is an absolute emergency that requires immediate action, rather than saying a reflexive yes to the request, take a pause, breathe in the question and really consider the following:

• Am I safe to practice more than my agreed hours?
• What other commitment have I made that is important to me to meet?
• Is it really my professional responsibility to agree to work extra hours?

Sometimes a request is accompanied by an emotional intensity that is even more likely to trigger guilt. “Can you work extra hours? I can’t find anyone else to do it.”

Again, create a pause. Breathe and consider:

• Am I safe to work those extra hours?
• If I say yes could I be placing my health and wellbeing at risk because I am tired and my thinking and responses are not work ready? Studies show that driving drowsy is as dangerous as driving drunk. You’d never work while drunk, so do you really feel safe working drowsy?
• Am I meeting the requirement of the Ethics the Code of Conduct for nurses or midwives? (Remember Principle 7: Health and wellbeing. You have a professional obligation to maintain your physical and mental health to practice safely and effectively.)

You should also ask yourself whether you are buying into learned behaviours that do not serve your wellbeing. Should you challenge the reflexive instinct to say yes to requests? Perhaps there could be benefits to challenging the role and updating the power of self-affirming responses.

3. Move your body

Our body holds so much of our stress, and does a great job of it for many years until it suddenly says: That's enough now. You can protect your body from long term stress-related damage by paying close attention to its needs.

Our bodies love to move, so honour your body by moving it, stretch, jiggle, dance, play. Identify the sore spots and gentle massage them. At the end of each day say loudly, “Thank you body, for the work you do to help me”.

4. Seek professional supervision.

Personally and professionally, I have experienced tremendous benefit from engaging in both individual and group supervision. In my experience, professional supervision has enabled me to challenge my practice and interaction through supportive relationships with supervisors I trust. I have offered professional supervision both individual and group for many years and professional boundaries is a common theme explored within the sessions I do. I recommend consideration of having professional supervision as an effective strategy to develop professional boundary skills. This is enhanced when the supervisor role models effective boundaries in that professional relationship.

If you’re interested in learning more about clinical supervision, Nurse & Midwife Support discussed the benefits with Mental Health Nurse Consultant Julie Sharrock in Episode 27 of the podcast.

5. Centre wellbeing in your decision-making

Travel the next part of your professional journey with your wellbeing at the core of your decision making. Professional boundaries is about you. Professional boundaries is about your safety and your wellbeing.

6. Listen to the podcast

In this podcast series, I share insights and strategies to develop and maintain professional boundaries. Setting boundaries in our life is necessary for our emotional, psychological, spiritual, and physical well-being. Setting boundaries is about our safety. Listen to the podcast to go on a reflective journey on your professional boundaries.

Listen to the podcast

7. Talk it over with Nurse & Midwife Support

If you’re struggling to assert boundaries and need somebody to bounce off or practice with, reach out to Nurse & Midwife Support to chat about it with experienced nurses and midwives who have experienced what you’re going through. Call 24/7 on 1800 667 877 or send an email.

Dr. Wendy McIntosh PhD RGN, RMHN, Grad.Dip MH, MN, Cert IV Workplace Assessment & Training, Group Leadership Cert, MRCNA, MANZCMHN, AMANZSPA.

Dr Wendy McIntosh currently works with the Davaar Consultancy to promote the importance of psychologically well employees to the delivery of safe and competent health care. Wendy has more than 30 years as a health professional (clinical, education and research), twenty-five of those years in mental health. Areas of specific interest and passion for Wendy include: professional supervision, professional boundaries, professional identity, links between childhood trauma and mental illness and workplace bullying. Wendy has more than 20 years as a psychodrama trainee – a life long learning. She is committed to using experiential learning in the work she does with individuals and groups. Regularly presenting workshops at national & international conferences, Wendy consistently receives feedback on her passion, knowledge and creativity as a presenter & facilitator.

Email Wendy