Ethics of Nurse/Patient Relationships

[patwil73]

I just finished reading the thread about dating a former patient. 11+ pages of strong opinion regarding the ethics of starting a relationship with someone you are caring for. I am not trying to restart whether or not people believe that particular poster was wrong or right in his decision, but instead in discussing the reasoning people use in deciding if it was ethical or not.

So for anyone interested in joining this discussion - do you believe that it is ethical to start a relationship with someone you cared for as a nurse?

Why?

From reading the prior thread many posters brought up vulnerabilty - that the power balance led to inequality between patient and nurse and hence it was morally wrong to exploit that inequality. If you do believe this, do you feel that all relationships that begin with one partner in a vulnerable state should not be pursued? Or any relationship that is unequal can not work?

Are all nurse patient relationship inherently unequal? Why? Does the patient not have the right to accept or refuse any treatment, to determine for themselves how their care will proceed, to even "fire" their nurse and demand another one? If the patient is A&O and at least semi-independent in ADL's where exactly is the inequality?

Many posters seemed to indicate that the ethics changed with time (many mentions of 6 months to 1 year). What exactly has changed in 6 months that didn't in 1 week? (and honestly, how many relationships survive 1 year of no contact?)

So have at it! Can the nurse patient relationship survive? Should it? Or are there perhaps other reasons we should strive to sever that possibility?

Thanks

Pat

PS: For those who think I might have an ulterior motive, I am happily married with my wife reading over my shoulder. She has let me know, in no uncertain terms, that violating that relationship will lead to a significant change from me being a nurse - to being the patient!:no:

[heron, ASN, RN]

For me, the crux of the matter is one of power. There is an artificial intimacy in the caregiving relationship that would not necessarily exist if the caregiving relationship wasn't there. That intimacy must happen in order for us to provide proper care for the patient ... it really doesn't matter which needs we are meeting ... and discharge doesn't automatically stop the dynamic like turning off a light.

The six-months-to-a-year is just a guideline ... an estimate of the time it might take for a patient to get past the emotional effects of this artificial intimacy and meet a former caregiver on equal terms.

There are myriads of examples of nurse/former pt. relationships where the parties' hearts were pure and intentions were honorable. Personally, I think that if the connection was that compelling, it would survive a "cooling off" period after the professional relationship ended. It's the situations that are not so pure and honorable that are of concern here. Nurses are human, and we all have our dark side ... and patients have little choice about dealing with us while actively under our care. Our patients did not sign up to be exploited financially, emotionally, socially or sexually ... and safeguards need to be in place to keep less-than-honorable caregivers from doing so.

[Liddle Noodnik]

Not something I have ever done, but dating a patient's family member I do not see as a problem. But again if it were me I would most likely wait to accept that first date after the patient was discharge so that I would not accidentally say something that would violate patient confidentiality. I might also make a point that if they brought up their loved one I would not discuss anything medical about their family member for professional reasons outside of a casual, how are they doing.

Good points!

[patwil73]

Some interesting points have been made, here, and I find the issue is less clear to me than it was before reading this thread. I'm still inclined to view dating a former patient as a boundary violation, but I wonder if I might feel differently if I were younger and actively interested in a romantic relationship.

Thanks for your response. I see a lot of answers that involve "boundary violations" as a reason that a relationship between nurse and patient might be unethical. I get the feeling though, that it is one of those phrases that everyone seems to agree with without really explaining what it means.

There are boundaries between my postal worker and me - she delivers my mail, but doesn't come inside my house. We might say hi, but nothing really else. Does the fact that there are boundaries preclude us from forming a relation. Or does all of life involve boundaries that must be violated for any relationship to form?

Certainly, it seems like there must be some qualitative difference from meeting a potential life-partner versus dating a different former patient every week.

Qualitative difference yes, one is short term and one is long term. But is either unethical. I would actually argue they are not. As long as the relationship is honest - (I want to go out for dancing, see movies, etc - not anything more) then neither action should not be unethical.

I've actually used the ethical objection to gently fend off unwanted overtures, and I didn't feel dishonest doing so. Now that I think about it, it has been an extraordinarily rare event for a woman to "hit" on me away from work, but not entirely uncommon at work. I suppose it's conceiveable that I just look that good in my uniform, but it seems rather more likely that patients are more vulnerable, more dependent.

Could it be that at work, a potential partner begins with a lot more information to base on whether or not to flirt? You run into a pretty girl at the store - what does she know about you? Starting a casual conversation can be difficult (where did you get that bread?)

At work they know you are in a stable profession that pays well. You are presumably educated to work in the profession you do. And conversation has already been initiated by the demands of care.

In most workplaces if you meet someone - client, coworker, etc. - you already start with a lot of advantages. It is what makes those relationships so easy to build and why when people cheat in relationships it is often with coworkers. There is an intimacy built regardless of your profession. Since we use those advantages in every relationship, are we arguing that there is a "qualitative" difference in the nurse/patient relationship that would make the advantage so great as to be unethical?

More food for thought,

Pat

[patwil73]

For me, the crux of the matter is one of power. There is an artificial intimacy in the caregiving relationship that would not necessarily exist if the caregiving relationship wasn't there. That intimacy must happen in order for us to provide proper care for the patient ... it really doesn't matter which needs we are meeting ... and discharge doesn't automatically stop the dynamic like turning off a light.

Thanks for the reply. You begin by mentioning power as the crux, but then speak soley about intimacy. Do you believe that all relationships are inherently equal or that the inbalance of power is not as great as in a nurse/patient relationship?

I do agree that the sicker a patient is, the more the pendulum of power swings towards the nurse. The more the nurse is responsible for completing for the patient - that a normal healthy person could do for themselves - the more a false sense of need could arise. However, since all relationships (in my opinion) have some inbalance of power I don't think it makes it unethical to pursue one simply since that inbalance exists. Is there a point where it is so great that it would be immoral? If so what is that point and how does nursing create or foster it?

The six-months-to-a-year is just a guideline ... an estimate of the time it might take for a patient to get past the emotional effects of this artificial intimacy and meet a former caregiver on equal terms.

How would one go about developing a relationship that you know is going to wait for 6 months to a year? How do you tell someone you like them but don't want to see them until 12 months have passed?

There are myriads of examples of nurse/former pt. relationships where the parties' hearts were pure and intentions were honorable. Personally, I think that if the connection was that compelling, it would survive a "cooling off" period after the professional relationship ended. It's the situations that are not so pure and honorable that are of concern here. Nurses are human, and we all have our dark side ... and patients have little choice about dealing with us while actively under our care. Our patients did not sign up to be exploited financially, emotionally, socially or sexually ... and safeguards need to be in place to keep less-than-honorable caregivers from doing so.

You a right that safeguards should be in place to prevent exploitation. But we are talking about adults who supposedly should be able to decide for themselves whether or not exploitation is taking effect. It seems somewhat Orwellian or "big brother" to pass restrictions on something positive (ie a relationship) because people can do bad things with it. I know we as a society have often chosen to do so, but I wonder if the ethics of protecting the minority of vulnerable population really should outweigh the ethics of self-determination in the majority?

Thanks again for your response.

Pat

[patwil73]

As the size of the thread grows often the original point can be lost. For those reading through we are attempting to discuss the ethics of dating a "former" patient, not someone who is currently a patient.

Thanks

Pat

[lpnflorida]

While I love ethical discussions, oh to be able to afford to live the life of the great philosophers. Assuming of course I would be smart enough lol...

I have accepted, my belief in the principled approach of Kant in this instance. While we can argue till the cows come home that no single theory rules in each and every instance. That is why we employ facts, assumptions, values or principles into why we do what we do.

Why do I accept the principled approach in this instance? bottom line it keeps me out of the grey area , preserves my ability to work with all patients no matter age, sex, or how strong the attraction might be, to give them the best care that I am able to. To maintain my objectivity with them. I lose my objectivity and I might throw in the hat. I would no longer be of benefit to my patient.

Same reason as why we do not treat/nurse our loved ones on the job. Objectivity is lost, we are then ruled by our emotions first.

I hope you are not just doing this thread for a class as opposed to a mental gymnastics . As I have said I loved ethics classes, but sure am glad am not still in them.

[ohiobirds99]

From reading these threads its very apparent that CEU'S in the nurse practice act and ethics is greatly needed.

I would encourage nurses from all realms refamiliarize themselves with their nurse practice act and take a peek at an ethics course online or else where.

You may find yourself a bit suprised at to what violations are as you find yourself going down that slippery slope.

You can not date former patients, you can not date a family member of a patient, even what appears to be an "innocent" comment that self discloses is a violation.

[bsveillon]

I think alot has to do with the scenerio that made the pt a pt----Say Nurse Suzy is taking care of Patient A who just had an appy. Pt A tells nurse Suzy he was supposed to go to the blues concert tonight but now cant, Nurse Suzy says Oh I love that blues band etc etc etc and a conversation begins, a few weeks later nurse Suzy and Patient A are now at the same bar watching the same show and Pt A buys nurse Suzy a drink and a relationship begins....perfectly fine if you ask me.

Or Nurse Suzy is taking care of Pt B in the Behav Health unit, had read pts Bs chart about his past relationship troubles-job trouble etc etc etc and Nurse Suzybeing a bit crazy her self (lol) and thinks Pt B is "hot" so she calls him after he is dismissed at home to "just talk" and see how he is doing etc etc etc and a relationship begins, well this is bad if you ask me.

I dont think this is a black and white question. Lots of grey areas!!! But good topic though!!

I think the scenario of Nurse Suzy and Pt B is highly unethical only for the reason that she is using information for purposes other than the reason it was gathered. That's not too cool.

[Old.Timer]

If we succeed in helping the pt to feel better, physically and emotionally, we have done a good job. However, this engenders normal responses in the pt. ... liking, gratitude, all kinds of warm fuzzies. And that response does not disappear upon discharge.

It is this positive emotional response that we CANNOT capitalize on to meet our own needs.

Nope, it's far more serious than that. It has to do with the problem of using a professional relationship to meet one's own needs. The emotional bond established during the caregiving relationship is, almost by definition, an artificial one resulting from our professional duty to care and the patient's natural reaction to being cared for. It is unethical to exploit that bond to meet the professional's personal needs ... whether for friendship, money or intimate attachment.

Thank you so much Heron! You have expressed my thoughts exactly .... word.for.word. I too believe that it is an artificial intimacy and we are ethically bound not to exploit it.

[pedicurn, LPN, RN]

Thanks again for the reply. I must say I am enjoying this discussion.

I might be misunderstanding you, but it seems you are arguing that since bad things can happen when you have private information about a person then you should not pursue a personal relationship. All relationships are built on personal information and when the relationship goes sour there is always the chance that you will say or do something which you wish you could take back. However, just because the potential for ruin is there, it does not necessarily follow that one should not pursue a course of action.

Wherever you get the information does not change the fact that it can be used well or poorly. Just having the information should not in of itself immediately make a relationship unethical, it is how you use that information - at least in my opinion.

Thanks again,

Pat

I think the big point is then ...

- The nurse has everything to lose

- The patient is allowed to try and pursue a relationship with the nurse; and has nothing much to lose unless there are vulnerability issues

And so, the nurse should be protecting herself /himself