If you were asked whether it is ever acceptable for a nurse to embark on a sexual relationship with a patient who is vulnerable, you would more than likely answer ‘no’. Would that answer change however if, in retrospect, you knew the pair were now happily married with children and the nurse had an otherwise flawless career record? And would it make a difference to you if that nurse was a mental health nurse?
In January the NMC faced these very questions when it considered the case of Karen Wilson, an adult psychiatric nurse who became involved with a ‘vulnerable service user’ – now her husband and the father of her children. At the fitness-to-practise panel hearing Ms Wilson was found guilty of misconduct but, when taking into account her unblemished nursing career, the regulator decided to caution her rather than strike her off the register.
To some, the decision to find her guilty of misconduct may seem ridiculous, while to others the decision to keep her on the register may seem equally wrong. Ms Wilson’s case is just one that highlights the complex issues that surround nurses becoming sexually involved with their patients. So exactly where should nurses draw the line about becoming involved
with their patients?
Nurses have a duty under the current NMC Code of Conduct to maintain professional boundaries with patients at all times. In the same month as Ms Wilson’s case was heard the Council of Healthcare Regulatory Excellence (CHRE) – the body that oversees the NMC and other healthcare regulators – released stringent new rules on what is and is not acceptable behaviour.
The new guidance states that: ‘A breach of sexual boundaries occurs when a healthcare professional displays sexualised behaviour towards a patient or carer’. The CHRE makes it clear that any form of sexualised behaviour with a current patient is unacceptable. It also says that relationships with former patients will ‘often’ be unacceptable.
While some nurses may assume that ‘sexualised behaviour’ relates only to physical acts, the examples outlined by the CHRE are extremely wide-ranging. Such behaviour can include anything from going on a date or using sexual humour during consultations to criminal acts such as sexual assault and rape.
Nurses would not, of course, condone abuse. When it comes to accepting dates or being romantically involved with former patients, however, their views are much less black and white.
An exclusive NT survey of more than 3,500 nurses revealed that this is an area where the opinions of professionals differ wildly. It also revealed that nurse/patient relationships are probably a lot more common than regulators would like to think.
While less than 1% of survey respondents confessed to having a sexual relationship with a current patient themselves, 16% said they knew a colleague who had done so. When it came to relationships with former patients, the figures jumped significantly –6% admitted to having had a relationship with someone after the care period had finished and 38% said they knew a colleague who had acted similarly.
Dating also proved a controversial area, with 6% admitting they had been on a date with a patient under their care. Only a fifth of respondents said it would never be appropriate in any circumstance to accept a date with a patient.
So can ‘love’ ever be a justification for going on a date or embarking on a personal relationship with a patient? In the CHRE’s eyes the answer is no. And, it warns, health professionals who argue that ‘they fell in love with the patient’ are, in fact, just trying to justify inappropriate behaviour. However, of the nurses responding to the NT survey, 9% said they thought that in some cases it could be a justification for starting a relationship with a current patient, while 72% saw it as a justification for starting a relationship with a patient who was no longer in their therapeutic care.
‘It should be my choice,’ argued one survey respondent. ‘Would an MP be denied the right to ask one of their constituents on a date or a tree surgeon one of their customers?’
Nursing unions are concerned that the survey reveals significant confusion among nurses as to where professional boundaries lie. Such confusion, they say, could put both patients and nurses at risk. As Gail Adams, Unison’s head of nursing, explains: ‘While we definitely concur that nurses shouldn’t have relationships with someone who’s currently in [their] care, that may be different for someone you briefly nursed many years ago’.
That said, some nurses believe that making the code of conduct more stringent, rather than less so, may help nurses to make the right decision when faced with such situations. Gill Devereaux, Unite/CPHVA professional officer, says: ‘I think there are so many permutations and so many different scenarios that the guidance has to be black and white. It’s a professional relationship and that’s where it has to stay for the protection of the vulnerable. Otherwise people do not know where the line is and it becomes open to interpretation and subjectivity.’
Another individual who wants greater clarity is Eric Phillips, who was struck off by the NMC last year for embarking on a sexual relationship with a mental health service user, with whom he is now in a long-term relationship.
‘I didn’t think the guidance was helpful. There was nothing in the guidance that said you mustn’t embark on a relationship until ‘x’ period of time has passed or that you mustn’t do it at all.’
But if there had been, would he have still started the relationship? ‘Yes, indeed, but I would also have made the decision that nursing wasn’t for me,’ he argues.
And it is not just the nurses who become romantically involved with their patients who may find themselves in tricky
situations – it can also prove difficult for their fellow nurses.
‘A colleague of mine is currently cohabiting with a dialysis patient,’ explains one survey respondent. ‘The only response from management is that the nurse should no longer dialyse the patient but she is often present on the unit at the time of treatment. Many of us find this situation uncomfortable.’
More importantly, nurses who know of colleagues involved with patients have a duty under the NMC code of conduct to report the behaviour. If they don’t, they too run the risk of finding themselves up before a fitness-to-practise panel.
‘It’s a harsh reality but if you’re aware a relationship is developing between a colleague and a patient and you let it go unchecked, there could well be an issue about your own conduct in relation to the code,’ points out Howard Catton, head of policy development and implementation at the RCN.
Of course, reporting a colleague can be a difficult business. One respondent said: ‘I reported [a colleague] for misconduct and he was sacked. I was bullied and targeted by colleagues after that for being the whistleblower and was not supported. However, I would do the same again’.
Ms Devereaux says better education is the key to improving clarity on both where to draw the line and how to report the behaviour of others. ‘The NT survey makes quite clear that we do need better education and training so nurses understand where those boundaries lie’.
What nurses said about relationships with patiets
‘A blanket ban on dating former patients is an infringement on our civil liberties’
‘It is never appropriate to ask a patient on a date’
‘When my nurse manager started a relationship with a patient while he was critically ill it was hushed up’
‘I went on a date with a patient and we married 18 months later’
‘A sexual relationship with a former patient is fine – I wouldn’t be here otherwise!’
‘This is all about fulfilling the needs of the professional who should know better’