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Legal / Ethics

When does a nurse-patient relationship cross the line?

I’m a medical-surgical nurse at a large urban hospital. Five days ago, I was assigned as the primary care nurse for a patient—let’s call him Dan—who’s recovering from injuries caused by a motor vehicle accident. He’s a 45-year-old personal injury attorney, good-looking, with a great sense of humor.

In the last 2 days, he has made it clear he’s attracted to me—and the feeling is mutual. Today, he asked if I’d have dinner with him after his discharge. He also offered me a part-time job working as a legal nurse consultant (LNC) in his law office, and said he’d pay the $3,500 tuition for the 4-week LNC training program.

Is it wrong for me to even consider dating him? We’re both single and seem to share a lot of interests. Still, I have this nagging feeling I’d be crossing an ethical line if I got involved with him romantically, accepted tuition money from him, or went to work for him.

Should I request an immediate transfer to a different unit so I can date him now? Or should I try to keep things on a professional-only basis for the time being, saying “no” to a date but accepting his offer to pay my tuition? Or should I play it safe and wait until a few weeks after his discharge before considering taking our relationship beyond that of nurse and patient?

— C.W., BSN, RN

The act of providing nursing care may sometimes seem to confer an intimacy with a patient—and this may foster feelings that go beyond the professional.

However, as a nurse, you’re obligated to keep your relationships with patients strictly professional. The nurse-patient relationship is a professional one; it shouldn’t be used as a springboard for a personal, romantic, business, or financial involvement. Dating Dan would be legally and ethically improper. Transferring to a different unit wouldn’t change the underlying issues or remedy the situation; you’d still be bound by nursing ethics.

Being clear about boundaries
As a licensed healthcare professional, you’re responsible for establishing and maintaining professional boundaries with patients. Failing to do so can be disastrous. State nurse practice acts, state board of nursing regulations, and in many cases both, require nurses to practice according to the standards of safe nursing practice and to make patient safety a priority. Also, many employers have codes of ethics or policies that address nurse-patient boundaries. Suspicion of boundary violations can spur an employer’s internal investigation or a disciplinary investigation by the state nursing board.

Unlike a friendship, which may evolve over several months or years, the nurse-patient relationship develops in the context of care provided to the patient and ends once the nursing care plan goals have been met or the patient is discharged. Even when a nurse provides care to the same patient over several months or years, as in a home care or long-term care setting, the nurse-patient relationship is structured. The relationship ends when the therapeutic relationship ends.

Power position
In the nurse-patient relationship, the nurse holds a position of power and authority. Patients trust and respect us. They look to us for care and comfort during what’s often a highly stressful time, when they may be vulnerable and more susceptible to influence. Professional boundaries exist to protect them.

Romantic and business involvements with patients aren’t the only types of boundary taboos for nurses. Others include:

  • accepting money or gifts from patients
  • giving money or gifts to patients
  • having social contact with former patients
  • getting too involved in a patient’s personal affairs
  • buying real property or personal property from patients or selling such property to them
  • developing a multifaceted relationship (such as a combination of business, personal, sexual, or financial) with a patient.

Cooling things off
Waiting a few weeks after Dan’s discharge before dating him would not be “playing it safe” because that’s too soon after his discharge. Review your state nurse practice act and board of nursing regulations to determine if these require you to establish a cooling-off period—a defined interval after the professional relationship ends—before you can initiate a personal or business relationship with a patient. But even if your state’s nurse practice act and board of nursing regulations address the professional boundary issue but don’t specifically stipulate a cooling-off period, a cooling-off period may be implied. Depending on circumstances, a reasonable cooling-off period is at least 1 year after the nurse-patient relationship ends or the patient is discharged.

Detaching from Dan
If you’re in doubt as to how to interpret nursing law, ethics, and professional practice standards, consult a legal expert. In the meantime, the American Nurses Association’s Code of Ethics for Nurses requires that you promptly remove yourself from serving as Dan’s nurse. Speak with your nurse-manager about the situation and ask that Dan’s care be transferred to another nurse.

One more thing: If you decide to pursue a personal relationship with Dan after waiting out the cooling-off period, think twice before letting him pay your tuition or working as his LNC. Being romantically involved with your employer (if that’s what he ultimately becomes) can lead to a host of ethical and legal dilemmas.

— LaTonia Denise Wright,
Attorney at Law
Home health nurse (per diem)
Cincinnati, Ohio

The information above does not constitute legal advice. For a complete list of selected references, see June 2007 references.

 American Nurse Today would like to thank Nancy Brent, MS, RN, JD, and LaTonia Denise Wright, BSN, RN, JD, cochairs of the Publication and Products Committee of the American Association of Nurse Attorneys, for organizing and coordinating this article.

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