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When Nurse-Patient Boundaries Blur, in Fact or Fiction

March 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.

Courtesy of the author

Courtesy of the author

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.

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7 comments

  1. Excellent post! I do think that these boundaries may flex based on the type of care and patients you deal with every day, possibly even over the span of a nursing career. Pediatric oncology patients require treatment and follow up for years, so you get to know them and their families more than many areas. It’s a gentle balance, best done with grace, open ears and eyes, and many smiles.

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  2. I often find myself wishing for the good old days when your family doctor was truly a part of your community. Back in the prairie days, docs and teachers would rotate staying in family’s homes and often ate dinner with people in their community. People appreciated their care and the medical provider had a vested interest in helping people. Too often, many health care providers don’t really know anything about their patients and aspects that influence the decisions they make in life. We are such a litigious society and providers are all about the numbers game. I have socialized with patients outside of taking care of them at work. (My husband and I have gone to the movies with a patient and her daughter, and they have come to our home for dinner) That doesn’t mean that I would ever do something for them extraordinarily or outside what the normal care would entail. They know that once I leave work, I don’t cross that line again until I clock in the next morning. You have to make hard fast boundaries such as I NEVER write any controls for anyone that I have ever seen outside work. I don’t show favoritism in scheduling or callbacks. I don’t discuss their healthcare outside of the office. If they need a script for something, they have to see me in the office and it’s all documented in their chart.
    I work in a very small community and every day people ask me how so and so is doing or that so and so sent me to see you because you take such great care of them and you really listen to their concerns. I find it stupid that I cannot officially acknowledge the fact, due to privacy laws, that I do take care of people here. It’s not like they don’t know already. They just passed each other in the waiting room for God’s sake.
    Well, now that I’ve typed this much about it, I’ll go blog about it too!

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  3. I am a new nurse. I work in community healthy in a group- home setting. I have the same 2-3 patients who reside in the home. I get to know them and their families. The other day I was told by the residen’t mother that I was like a daughter to her, and she said ” I love you, and said it again. I really felt uncomfortable, thinking of what a violation of patient nurse boundaries, and what have I done to elicit that response. is there something wrong with me? I simply said thank you, I do my best. It is my job to take care of your family member” It is almost akin to being a private nurse for someone. In this setting I can see how boundaries blur. I am just using common sense, and setting emotional boundaries. If you are too emotionally attatched to patients or their families, you may not make good clinical decisions in their best interest. However, that is not to say one should be a callous, robotic nurse. It is a delicate balance, and really depends on the setting you work in.

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  4. I am reminded of this daily in my specialty, where we see patients over months, sometimes years of their lives. I do believe the moral thermometer is important and balance is key.

    There are some patients I will just never forget, for better or for worse. And I remember them with awe and sometimes fondness, because they remind me of why I do what I do everyday.

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  5. Good insight into what can be a tricky situation to navigate. Glad to see your post.

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  6. I feel that boundaries in any relationship is important for me to identify my motives. May I not lose site of the importance of seeing everyone as a human being in need of sincere caring and empathy. Like in all aspects of life there has to be a balance and “moral thermometer”. Allowing our patients to share personal likes and interests is part of hearing them. If we want to give in return, i.e. a book, CD etc. then I do not see this as a problem or leading to a problem of crossing boundaries. Again checking our motives and keeping ourselves in check is what matters in all relationships.

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  7. Excellent, Marcie. In the outpatient setting, most patients are conversant and pleasant: I understand the feelings you developed with this patient.
    I have the same problem with A Farewell to Arms, with the additional comment that I can’t stand the flowery dialogue between the lovers, yuck.

    However, I’m a little confused from time to time when I meet couples, married for decades, who began their relationship as nurse/patient. Should they be denied their happy marriage? As you point out, exactly where is that thin red line?

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