Boundary Violations among Outgoing Undergraduate Nursing Students: Mixed Method Approach

 

Ankita Manral¹, Bharat Pareek², Rupinder Kaur³

¹M.Sc Saraswati Nursing Institute, Dhianpura, Kurali, Roopnagar (Punjab), India

²Associate Professor, Saraswati Nursing Institute, Punjab

³Lecturer, Saraswati Nursing Institute, Punjab

 

ABSTRACT:

Aim:  The aim of the study was to determine prevalence of boundary violation and narrate lived experiences of undergraduate outgoing nursing students of various nursing educational institutions in Mohali and Ropar district. Material and method: A mixed method approach was used where cross sectional descriptive survey supplemented by in-depth interview was employed. The conceptual framework used to guide this study was based on Theory of Planned Behavior and Theory of Reasoned Action. Nursing Boundary Index Self-Checklist was developed, used to determine prevalence of boundary violation where as in-depth interview was conducted to narrate the lived experiences of study subjects.  A total of 286 nursing students were selected using convenience sampling for survey and 11 subjects selected for in-depth interview using critical case sampling technique. Quantitative data was analyzed using SPSS.V22 whereas qualitative data was analyzed using colaizzi’s approach. Results:  The overall prevalence of boundary violation among outgoing nursing students was 9.62%. Prevalence rate of boundary violation were explored for role boundaries (28.45%), Time boundaries (17.10%), Intimacy boundaries (15.0%), Language boundaries (8.30%), Social boundaries (8.0%), Self-disclosure boundaries (5.70%), Cloth boundaries (5.60%), Physical boundaries (4.80%), Place boundaries (3.50%), Gift boundaries (2.70%) and Social-sites boundaries (2.20%). Age of the subjects and course enrolled with was observed significantly associated with boundary violation (p<0.05).The themes related to boundary violation that emerged from qualitative data analysis were Social relationship, Negligence/Malpractice, Over involvement, Role related issue, Verbal aggression, Accepting gifts , and Unprofessional Attitude and Time related violations. Conclusion:-The study concluded that overall prevalence of boundary violation among outgoing nursing students was low and observed associated with age and with course enrolled with subjects.

 

 

INTRODUCTION:

Professional boundaries are the guidelines that help and protect the nurses as well as patients. In the professional relationship there is a difference between the healthcare professional and the patient’s vulnerability. This difference creates the need to keep safe professional boundaries for nurses and patients.¹ The nursing profession, have a highly respected position in the Society. This position is threatened not only by the overt unprofessional behavior and attitudes of some individual, but also by ongoing changes in the health care system. Rapid advancement in medical knowledge and technology are putting increase pressure on nursing professionals to possess huge quantities of information, with requirement of continuous learning, updating knowledge and skills which are time consuming but essential. All these change have created an environment that may have a negative impact on professional behavior and leads to boundary violation. These new demands and the expectations of the public and the medical community have altered the image of the medical and nursing professionals.²

 

MATERIAL AND METHOD:

For Quantitative Part:

A cross sectional descriptive design was employed. The conceptual framework used to guide this study was based on Theory of Planned Behavior and Theory of Reasoned Action. Nursing Boundary Index Self-Checklist was developed, used to determine prevalence of boundary violation. A total of 286 subjects were selected using convenience sampling for survey. Content validity, Convergent and Construct validity of Nursing Boundary Index Self-Checklist were determined. Reliability was checked in terms of internal consistency (P=0.97) and Stability (P=0.75). Pilot study was conducted on 30 subjects and feasibility and sample size for main study was determined. Confidentiality was assured for all the information provided. The data has been collected from 286 subjects (Outgoing nursing students (male and female) of undergraduate programs) studying under various nursing institutes situated in Mohali and Ropar district. Quantitative data was analyzed using descriptive and inferential statistics.

For Qualitative Part:

In present study, a descriptive phenomenological design was adopted to narrate the lived experience related to boundary violation among outgoing nursing students. Survey subjects those observed with high prevalence with boundary violation were selected using critical case sampling technique. A total of eleven subjects (data saturated) were interviewed in-depthly. The venue for interview were planned and conducted at subjects own institution. In present study investigator herself conducted interview to facilitate the discussion, subjects were encouraged to speak and narrate their experience related to boundary violation. Each subject was interviewed once. Average time for each interview was one an half to two hours. Furthermore, subjects were informed about audiotapes recording. Written notes and audio recording of interview were used as a source of information and ongoing data analysis was done. Colaizzi’s approach was used to interpret the in-depth interviews.

 

RESULT:

For Quantitative Analysis:

Objective 1: To assess the prevalence of boundary violation among nurse students using Nursing Boundary Index Self –Checklist.

The overall prevalence of boundary violation was 9.62%. Prevalence rate of boundary violation among study subjects was higher for Role boundaries (28.45%) and least for Social-sites boundaries (2.20%) or Other areas of violations explored were Time boundaries (17.10%), Intimacy boundaries (15.0%), Language boundaries (8.30%), Social boundaries (8.0%), Self-disclosure boundaries (5.70%), Cloth boundaries (5.60%), Physical boundaries (4.80%), Place boundaries (3.50%) and Gift boundaries. (Figure 1)  N=286

 

 

 

Figure 1: Prevalence of Boundary Violation among study subjects. 

Objective 3: To determine association between prevalence of boundary violation and socio demographic characteristic of outgoing undergraduate nurse students

(Table 1) depicts association between boundary violations with socio-demographic variable with study subjects. Age and the course of the subjects were observed significantly associated with overall prevalence of boundary violation, whereas variable such as gender, religion, 10+2, current habitat, native place, current location, college management, parental hospital were not associated with overall prevalence (p<0.05)

 

 

 

Table 1; Association between boundary violation and selected socio demographic variables of subjects.                N=286

 

For Qualitative Analysis:

Objective 2: To narrate nurse student’s experiences related to professional boundary violations.

For analysis of the data colazzi’s approach have been used, extracting significant statements, resulted into emergence of eight themes i.e. social relationship, negligence/ malpractice, role boundary, unprofessional attitude, over involvement, verbal aggression, gift boundary, time boundaries.

 

Description of Emerged Themes-

1. Social Relationship:

 It was emerged that nursing students having problem to maintain boundaries of professional and social relationship. Common experience explored by the subjects  such as “ Student nurses exchange their personal cell number with patients” patient’s family or with doctors for social purpose” Establish relationship with patients and their relatives” Meeting with patient’s family member outside the hospital” Go for outing with staff ” Get connected with patients on social networking site.”

 

2. Negligence/ Malpractice:

Negligence/ Malpractice emerged with the supporting statements such as,” Ignoring patient’s problem as many times they consider their own work was their first priority, Violation of protocols/guidelines, Substandard care, Ignorance.”

 

3. Unprofessional Attitude:

Unprofessional attitude was emerged with the supporting statements such as, “Student nurse doesn’t show interest in patient’s care, don’t like to interact with patient’s, think there is nothing to learn new, Un-cooperative staff, Low standards of colleges affect the practice, works well in the presence of doctors and relatives, provides care to the patients with whom they have good bonding”.

 

4. Verbal Aggression:

Verbal Aggression emerged as another important aspects with the supporting statements such as,” patient’s relatives pass comments on nurse’s dress, have argument with staff, get irritated when patients argue while providing care, Use abusive language for patients, shows aggression toward patient when they resist care.”

5.       Role boundary:

Role boundary related issues expressed by the subjects and emerged as a theme with the supporting statements such as, “Senior staff work was done by junior staff or by student nurses even they do not know how to do it, criticizes junior staff, intend to make their work done by student nurses, Every time senior makes their own order, always dominating in hospitals”.

 

6.       Over involvement:

Issues and violations of professional boundaries in terms of Intimacy were emerged with the significant statements such as” Focused care helps in early recovery of  male patients, Feels attraction toward opposite gender,  Student nurses like to spend more time in male wards.”

 

7.       Gift boundaries:

 Gift boundaries was emerged with these sub themes such as, “Nurses accepts   gifts or money, Accept  gifts at time of discharge, Give personal token to patients to make IPR with patients, Student nurse  receives token as a gratitude of patients care.”

 

8.       Time boundaries:

Time boundaries related issues expressed by the subjects and emerged as a theme with the supporting statements such as, “Spend extra hours for the patient with whom they have a good bonding” “Nurses are not punctual for drug administration of patients” Student nurses avoid their responsibilities regarding patients care assignment”

 

DISCUSSION:

The current study focused on to determine prevalence of boundary violation and narrate lived experiences of undergraduate outgoing nursing students. Study findings showed the overall prevalence rate of boundary violation was 9.62%.  Prevalence rate of boundary violation among study subjects was higher for Role boundaries (28.45%). It is consistence with the findings of study done by Griffith et.al (2013)³ result showed complaints of failure to maintain professional boundaries are increasing among nurse-patient.

 

In present study quantitative analysis revealed that many subjects having social boundary violation (8.0%).  It is consistence with the finding of the study done by Almari Ginary D.O et.al (2012)⁴ revealed that 9.7% nurses receives friend request from patients and it is also consistent with the finding of qualitative analysis where social relationship related issue emerged as main theme. Similar finding reported by Piscotty. R et.al (2016)⁵ result showed that use of social media like checking message, chatting, and calling activities are frequently observed among nurses that shows irresponsibility during working hours.

 

Present study revealed that with increasing age boundary violation occur more frequently. It is consistence with the findings of study done by Campbell RJ et.al (2005)⁶ reported committing the most serious violation with increasing age. 

 

Present study revealed that students pursuing B.Sc. Nursing have more professional boundary violation than others. Similar finding were reported by Jeffrey S. J et.al (2008)⁷ were Associate degree registered nurses had higher frequency of boundary violations.

 

In present study findings of qualitative analysis showed that social relationship, intimate relationship, role boundary, gift boundary related issues emerged as central theme. Similar finding were reported by Manfrin-Ledet L et.al (2005)⁸ in which role reversal, gifts and money, over involvement, sexual behavior, social media emerged as main theme.

 

IMPLICATIONS:

The nurse–patient relationship should always be maintained for the benefit of the patient and not the personal gain of the nurse. “The nurse’s primary commitment is to the patient” (American Nurses Association, 2001).The findings of the study have several implications which are implicated in different areas of nursing, to develop a therapeutic relationship and set appropriate boundaries with their clients, use professional judgment to determine the appropriate boundaries of a therapeutic relationship with each client, organize in service educational programme to maintain therapeutic relationship and professional behavior between nurse and client and research should be conducted on how professional boundary violation affects quality of care ,research should be conducted to manage boundary violation among nurse-client relationship.

 

LIMITATION:

·       There were only two male subjects.

·       Thus It  has limited generalizablity

·       Social desirability bias.

 

RECOMMENDATIONS FOR FURTHER INQUIRY AND RESEARCH:

Based on study limitations, there are several recommendations for future research:

·         On the basis of the findings study can conducted to explore spectrum of boundary violation in the nurse patient relationship.

·         A qualitative study can conducted to report early socialization and carrier choice in nursing.

·         An observational study on Professional boundary violation can be conducted.

 

CONCLUSION:

The study concluded that overall prevalence of boundary violation among outgoing nursing students was low and observed associated with age and with course enrolled with subjects.

 

ACKNOWLEDGEMENT:

I would like to acknowledge the study participants for providing me their responses. My sincere thanks to all those who assisted me directly or indirectly in the successful completion of this study.

 

CONFLICT OF INTEREST:

The study entitled “Boundary Violations Among Outgoing Undergraduate Nursing Students: Mixed Method Approach” is self-funded research work of Ms. Ankita Manral. So there is no conflict of interest.

 

REFRENCES:

1.     Margarita Baca. Professional boundaries and dual relationship in clinical practice. The Journal for Nurse Practitioners 2011. doi: http://dx.doi.org/10.1016/j.nurpra.2010.10.00

2.     Aravind V.K, Krishnaram V.D, and Thasneem Z. Boundary Crossing and Violation in   Clinical Setting. Indian Journal of Psychological Medicine 2012 Jan-Mar; 349(1); 21-24,  doi:10.4103/0253-7176.9615

3.     Griffith, Richard, Tengnah, Cassam. Maintaining Professional Boundaries. British Journal of Community Nursing 2013 Jan; 18 (1):43-46

4.     Almari Ginary D.O¹, Laura Mayol Sabatier M.D, Spencer Eth M.D². Addressing Therapeutic Boundaries in Social Networking 2012 Mar;75 (1). doi:10.1521/psyc.2012.75.1.40

5.     Piscotty.R, Martindell.E, Karim.M. Nurses self-reported social media and mobile device in the work setting. Online Journal of Nursing Informatics (OJNI) 2016 Feb.20 (1). http://www.himss.org/ojni

6.     Campbell RJ, Autim, Wendy. Intimacy boundaries between mental health nurses and psychiatric patients. Journal of Psychosocial Nursing and Mental health services 2005 May 43.5:32-9

7.     Jeffrey E.Barnett. Mentoring, boundaries and multiple relationship opportunities and challenges. Journal Mentoring and Tutoring: Partnership in Learning 2008 Jan;16 (1),http://dx.doi.org/10.1080/13611260701800900

8.     Manfrin-Ledet L, Porche DJ, Eymard AS. Professional boundary violations: a literature review. 2015 Jun: 33(6): 326-32.doi: 10.1097/NHH. 0000000000000249.

 

 

 

 

 

 

 

 

 

Received on 30.08.2017          Modified on 18.09.2017

Accepted on  30.10.2017      ©A&V Publications All right reserved