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News Analysis: Are relationships with patients always out of bounds?

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Earlier this month healthcare watchdog the Council for Healthcare Regulatory Excellence (CHRE) released guidance warning nurses and other healthcare professionals of the risks in forming relationships with either current or former patients.

Not surprisingly, the guidance makes it clear that relationships with current patients or their carers are never acceptable. Nor is it acceptable to terminate a clinical relationship to pursue a social or sexual one.
However, it also warns professionals to tread carefully when it comes to relationships with former patients and carers, saying such liaisons will ‘often be inappropriate however long ago the professional relationship ended’.
‘If a healthcare professional thinks that a relationship with a former patient might develop, he or she must seriously consider the possible future harm to the patient and the potential impact on their own professional status,’ the guidance states.
While nursing unions agree that relationships with current patients are always unacceptable, the issue of former patients is, they suggest, a grey one.
‘I think there’s probably quite a number of couples to whom that would apply,’ said Gill Devereaux, professional officer at Unite/CPHVA. ‘If you think about soldiers who met nurses in the war or nurses who say: “Oh I met my husband when he was a patient on the ward”.
‘Of course you have to be professional at all times but if you bump into someone 20 years later, would it be unprofessional to have a personal relationship?’
Figures suggest professional/patient relationships occur more often than professionals might like to admit. Last year, the CHRE and the Department of Health commissioned a literature review on the issue.
It found 38–52% of healthcare professionals reported knowing of colleagues who had been sexually involved with patients, while 22–26% of patients said they had been sexually involved with a healthcare professional.
The question of whether or not a personal relationship is acceptable often comes down to timing, nursing unions argue.
‘What if a healthcare professional meets socially someone who they may have treated briefly on a couple of occasions in the past and a relationship begins to develop?’ asked RCN head of policy Howard Catton.
‘Obviously it needs to be handled carefully to ensure there are no issues around vulnerability and power but I’m not sure saying it will be inappropriate however long ago they were a patient is necessarily right.’
Gail Adams, Unison’s head of nursing, agreed. ‘It’s a question of timescales and settings,’ she said. ‘While it wouldn’t’ be appropriate for a nurse to start or be in a relationship with someone who they were currently treating, common sense should prevail. If there’s been a long time difference, it could be unreasonable to say people should not be able to have a relationship with any former patient.’
It is also likely that the area of clinical practice involved will also make a difference, with some patients, such as those in mental health or learning disabilities setting, more likely to be vulnerable than others.
‘Obviously in areas such as psychological therapies, a nurse may have a very different sort of relationship with a patient than one who removes a plaster from a broken limb,’ Ms Devereaux pointed out.
But even if relationships appear consensual, caution is necessary. If they ever become the subject of a complaint the onus is on nurses to show that they have acted professionally.
The fact that a patient initiated a relationship is unlikely to hold much sway if a nurse is called before an NMC fitness-to-practise panel, and using ‘love’ as a defence is unlikely to
prove successful.
The CHRE says professionals who breach sexual boundaries tend to use strategies such as minimisation, normalisation and denial when challenged about their behaviour.
‘This may take the form of justifications including: “the patient came on to me”, “she started it”, and “I fell in love with the patient”,’ it says.
To protect their professional reputation nurses need to be aware of what constitutes a breach of sexual boundaries. The CHRE says ‘sexualised behaviour’ can include anything from criminal acts, such as rape or sexual assault, to accepting a date or using sexual humour during consultations.
It calls on healthcare professionals to be self-aware and able to recognise behaviours that may be ‘precursors’ to a breach of boundaries. These include giving or accepting social invitations, exchanging clinically unnecessary communications, or seeing patients outside normal practice hours.
And it is not only the nurses crossing such boundaries who may face an NMC hearing. Those who do not report concerns about colleagues’ relationships with patients may also come under scrutiny.
‘It may be a grey area but you have a duty to report under your code of conduct,’ said Ms Devereaux. ‘If it ever came that you sat back and did nothing, then your professional status would be at risk. It’s about a duty to protect the public.’
Given the difficult nature of the subject matter, the CHRE has called for healthcare professionals to receive better training on the issue of realtionships with patients, both at pre-registration level and as a compulsory part of CPD.
‘There is training, but often it is at a low level and not a lot of time is given to it. So there’s more that could be done to raise the importance of the issue and provide training, not just early, but on an ongoing basis,’ agreed Mr Catton.
Ms Devereaux added: ‘It’s important to make it a part of CPD, because it’s an area where things change quite often in terms of legislation and case law – particularly on issues like sexual harassment. You have to be so careful. I think people need reminding.’
It certainly seems that regulators are becoming tougher on these issues.
In 2004 the NMC placed a caution on the registration of a nurse who started a sexual relationship with one of her patients who had been detained for treatment under mental health legislation.
At the hearing she admitted that the relationship was wrong but said it had been ‘love at first sight’.
But the CHRE guidance suggests this would now be unacceptable.
The CHRE says professionals must use their judgement when considering a relationship with a former patient, and seek advice from an appropriate professional body if they are uncertain.
Although the guidance offers a list of issues to consider, nurses may still be at risk if they go ahead with a relationship in today’s regulatory climate.
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