26.11.2020 in Psychology

Cerebral Palsy

The Ethical Boundaries of Nurse-Patient Relationships

The relationship line between nurses and patients is very thin and it is easy to cross the boundaries. The assumption may be of twofold implications for the outcomes of nursing care and practice as a whole. On the one hand, development of mutual understanding can be very helpful in this context as good patient-to-nurse relationships can be a source of open collaboration in the scope of care delivery. On the other hand, shortcomings in such relationships may result into the bad consequences for a patient, nurse, or both if these will be within the unethical dimension. Therefore, the paper presents a scenario to understand all positions thoroughly. Further, analysing the given case study as controversial from the ethical perspective as these pertain to both actors is important to clarify the mechanisms and strategies for weighted and informed decision-making. The findings of the paper offer a useful insight into measuring the boundaries between nurses and patients without institutional policies put in place. While the literature recommends avoiding the situations that can undermine the quality of care or reputation of a nurse, the current case can be an exclusion from the rule due to the previous friendship of the parties and the specificities of the patients condition.

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In order to be able to evaluate the arguments of taking sides in a thoughtful manner, it is necessary to consider the information about the entire situation at first. Thus, the issue relates to a registered nurse (RN) Sam Mills who is a specialist in a general practice setting. Despite the fact that he is one of 6 practitioners in the unit, all other professionals finished their shifts already. The other actor in the case is Lee, a patient with cerebral palsy who has a chronic health condition, such as a leg wound that requires regular redressing procedures. For this reason, Lee is a regular patient in the institution. During the procedure of redressing at the end of his shift at almost 6 p.m., Sam expressed his willingness to have a dinner at Vinnys pasta. The patient disliked eating alone. Hence, he suggested if he could accompany Sam so that they could have dinner together. While the nurse could politely reject the proposal in other case based on the ethical requirements to the nursing specialists that recommend do not compromise nurse-to-patient relationships with such activities, the given situation was rather complicated. The point is that Lee and Sam are next-door neighbours and long-term acquaintances. Moreover, since he is a care provider to a regular client, the patient might have an impression that he is ashamed to go to public places with him due to his long-term health condition among other issues. Therefore, rejection would definitely mean a form of offence. In this context, it is evident that Sams ill-considered idea of having a dinner posed a serious dilemma to him as a professional that should be carefully analysed in order to provide the best option possible. The fact that the care provider is pressed by the time as decision should be made fast is another factor for accurate examination of the case because it can be a useful lesson to take into account in my future practice as a nurse if I encounter similar situations.

Arguments against Having a Dinner with Lee

Primarily, the patients health condition must be the main driver for providers decisions and actions. Indeed, one should consider the fact that Sam had to think about the patient foremost before expressing his willingness to visit Vinnys pasta in light of the clients health condition as his decision-making capacity is unclear. While the case provided too limited information about the exact specificities of Lees type of cerebral palsy or any complications available, the practitioner could have predicted the implications of his words or actions before expressing them. In particular, apart from evident movement impairment, people with such diagnosis are likely to have numerous health complications that can either impact their capability to make reasoned decisions or make it hard for them to perform functions, especially on public. Cerebral Palsy Alliance provides a summary of common issues relevant for this population segment as showed in Appendix 1. Based on the information, it is possible to assume that a high likelihood exists that Lee can face some negative consequences as no specifications regarding his disease were provided. For instance, a practitioner cannot be sure if the patient has no epilepsy that is a common problem for 1 in 4 cases of cerebral palsy or whether Lee has no cognitive impairments to be in a position of making the relevant decisions. Therefore, the nurse needs to politely rephrase the proposed solution in order to secure the patient most of all.

Moreover, the rejection of Lees invitation can be justified by the professional ethical values which each nurse has to follow. To illustrate, referring to the Nursing and Midwifery Board of Australia (NMBA), one can mention the value statement 5 that requires a nurse to take into account patients informed decision-making which is quite arguable based on the above rationale of unknown implications of the patients disease on his capability to make sound decisions. In other words, it is doubtful whether Lee is able to verify the meaning and information being given to them when making decisions. A similar assumption can be made with regard to the value statement 6 that emphasises safety of nursing care. Because of that no information is available concerning health complications of Lees health condition, his safety might be undermined by this dinner.

In addition, even though the clinical setting has no specific policies regarding the analysed situation and clear establishment of nurse-patients boundaries, the main nursing regulatory body offers a recommendation framework for decision making in this respect. The NMBA has developed a number of steps to be considered in this case. For instance, the dinner invitation is neither a part of nursing care plan, code of professional conduct, nor policies available in the setting. For this reason, the framework suggests that the behaviour should be avoided. Hence, Sam needs to follow the regulatory guidelines and do not have a dinner with a patient.

Arguments for Going to Dinner with Lee

On the other hand, several arguments in considering this ethical dilemma allow supporting the likelihood of accepting the invitation. To start with, a specific health condition of a patient and the nurses position in the relationship can be a notable driver for Sams positive response to the request. Most of all, the issue relates to the mandatory respect to any patients dignity, especially based on ones health impairments. As aptly noted by health care theorists and practitioners, self-concept is the core of care delivery. The term entails a multidimensional systems construct that consists of personal beliefs, values and attitudes, which a person holds about who he or she is in relation to self-perceptions and others. This notion is directly related to wellbeing and quality of life of an individual as it comprises of many factors, ranging from psychological, emotional, social, and physical to spiritual ones. Thus, rejection of the invitation will most likely be translated into undermining the essence of Lees self-concept and perceived as disrespect to his self. The evidence exists that when a person with cerebral palsy faces limitations of ones opportunity to participate in public activities, such as the analysed dinner experience, they have decreased self-esteem, feel anxious and experience the lowered quality of life. Therefore, rejection of the invitation by Sam as a nurse and a neighbour can definitely be linked to the negative implications for Lees self-concept. In contrast, due to the fact that Sam is a care provider and a friendly neighbour for Lee, his dual role can be used for the best patients outcomes.

Referring back to the nursing ethics code, it is possible to identify the values and provisions that can be interpreted in support of the argument in favour of going to dinner. For instance, the value statement 2 states that nurses value respect and kindness for self and others. On the contrary, rejection will increase patients vulnerability that can be especially relevant for a person with cerebral palsy who is likely to experience a higher degree of vulnerability and powerlessness. What is more, the value statement 1 emphasises the necessity for quality nursing care for all people and the fact that nurses should strive to secure for them the best available nursing care. While the dinner is actually out of the scope of nursing care as Sams shift will be over by that time, this extended relationship can be useful for a more comprehensive care delivery by revealing respect to the patients appreciation and supporting his long-term acquaintance simultaneously.

In particular, nurse can become a valuable link to a more successful socialisation of a patient with cerebral palsy in public life and acceptance of Lees invitation can be a good contribution into the process. In accordance with Dark, Clemson and Balandin, people with such a diagnosis are likely to experience deterioration of communication abilities as they age. This factor implies further complications in terms of communication with others, expressing ones ideas, and having satisfaction from social interactions. Therefore, Sam can assist the neighbour with attending a public place as it is unclear if he visits such facilities with his friend. Besides, as a nurse, he can assess the patients communication and identify possible issues for further more detailed assessment of his communication needs, if needed.

Hence, a nurse can find out valuable information for better treatment outcomes for the patient, while maintaining the communication boundaries effectively and in a proper manner. For instance, nutrition is evidently a problem of Lee based on the fact he is sufficiently underweight as mentioned in the scenario. Thus, a dinner with Sam can assist a practitioner in increasing his awareness about Lees eating patterns. In this way, Sam as a nursing specialist can advise his neighbour regarding better food choices as he needs substantial calorie intake to handle his health condition well.

It follows that, since making the dinner an unethical conduct is considered, keeping the dinner in the constraints of the extended patient care should be maintained for the mutually beneficial outcomes. Communication is the key, and Sam has to set the limits in this respect. Thus, a nurse should identify specific taboo topics, such as no discussions of the colleagues, providing to intimate details on this account, or positioning himself as the best care provider for him among other issues. The same issue should concern the money: no presents should be accepted, while paying each for oneself has to be positioned as a manifestation of each others independency and clear explanation by Sam that this measure is critical for his professional ethics. The conversation during the dinner can be most successfully used for discussion of better patient outcomes for Lee as explained earlier.


Summarising the findings of the paper, it is evident that Sam faced an ethical dilemma in terms of nurse-patient boundaries when occasionally expressed the willingness to visit Vinnys pasta and Lee suggested that it would be great to have this visit together. In this context, Sam is the clients care provider and a next-door neighbour. On the one hand, the setting has no respective policies that would have forbidden the situation, though the regulations generally recommend avoiding it. At the same time, NMBA recommends avoiding such a conduct of dubious character in order to eliminate the possible negative consequences to nurses reputation as a whole. On the other hand, Sams aforementioned dual position obliges him to accept rather than reject the invitation. Evidently, he can better explore Lees health condition while establishing the care-focused boundaries for the conversations, such as advices concerning Lees nutrition or understanding his communication specificities, to list a few. This scenario will enable the nurse in assisting the patient with cerebral palsy in terms of enhancing rather than negatively impacting his self-concept, thus, life quality. Nevertheless, the regular nature of care for Lee allows suggesting that it would be better to delegate the care to his colleagues in the future.

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