When Nurse-Patient Boundaries Blur, in Fact or FictionMarch 15, 2013
By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Love Song of Frank,” was published in the May (2012) issue of AJN. She currently has an essay appearing in The Examined Life Journal.
Professional boundaries, as defined by the National Council of State Boards of Nursing (NCSBN), are “the spaces between the nurse’s power and the patient’s vulnerability.” The NCSBN describes the nurse–patient relationship as a continuum, with “too little care provider involvement” at one end and “too much care provider involvement” on the other.
The ideal therapeutic nurse–patient relationship lies in the middle, with “no definite lines separating the zone of helpfulness from the ends of the continuum.” I don’t love the indeterminate nature of that definition, but I understand it.
Some time ago, I was surprised by a friendship that developed between a patient and me. It was an unusual circumstance, in that the patient was in the ICU for a very long time for chronic problems that didn’t affect his mental capacity. I was his nurse many times, and through idle chatter during routine care we discovered not only a shared appreciation of literature in general, but a fondness for many of the same authors and books. I started thinking of books I’d bring him, hoping to augment the tedium of his hospital stay. At some point, I started thinking of him as a friend.
This had never happened to me before, probably because I work in a trauma ICU and the majority of my patients are intubated, sedated, or mentally altered for a variety of reasons. I’ve become friendly with patients’ family members, but have never developed much of a relationship with an ICU patient.
Although I don’t believe any boundary was crossed with this particular patient—and I never specifically thought about it in those terms—a personal red flag went up when I realized I thought of him as a friend. While this may or may not make sense to nurses in other specialties, to me it just felt strange, and I was relieved when my assignment changed and I was no longer his nurse.
Perhaps that same red flag is to blame for my dislike of Hemingway’s 1929 novel, A Farewell to Arms. Set in Italy during World War One, the classic novel has been lauded as a chronicle of self-discovery, full of passion and turmoil. Yet I found myself so put off by the main character’s love affair with his nurse, Catherine, that the book was ruined for me.
There’s no question of whether or not boundaries were crossed, no shadowy area in Hemingway’s continuum, as the relationship only blossoms after Frederic Henry is injured and Catherine becomes his nurse. There’s no ambiguity about the sexual aspect of their relationship, the nature of the banter they exchange while she’s caring for him, or the motives behind her selection of shifts—she stays on the night shift to spend more personal time with her patient. And Hemingway clearly acknowledges the existence, and transgression, of those boundaries—the characters take much care to keep their relationship a secret from the hospital staff.
But it’s literature, of course, and not life—it’s romanticized and dramatic, set in a foreign country . . . in a war. I know this, and I regret having felt so much prudish disdain over the actions of the characters that I couldn’t enjoy the book. But I couldn’t help it.
I suppose the sanctity of the nurse–patient relationship feels too important to play with, even in fiction. Boundary lines are boundary lines, after all, and when it comes to nursing, such blurring of them bothers me.