1. Section Editor(s): Witt, Catherine MS, NNP-BC

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We are privileged to work in nursing in an area where we are involved with families in the most intimate moments of their lives. The birth of a child is a momentous occasion. When the child is premature or ill and requires intensive care nursing, it is a traumatic and difficult experience for parents and families. Just as the babies we care for are our patients, the parents and other family members are our patients as well. As nurses, we are part of their experiences, both celebrating and grieving with them throughout the course of their stay in the NICU. And because many of our patients are in the NICU for an extended period of time, we develop close relationships with many of the families we meet.

Catherine Witt, MS, ... - Click to enlarge in new windowCatherine Witt, MS, NNP-BC

As expert nurses, we strive to provide family-centered care that is relationship based. Relationship-based care requires getting to know the patient and family and the individual needs of that patient. It requires establishing a level of trust so that patients can let us know their values, their fears, their desires, and how they desire to manage their own journey. It means making the patient and family the center of our focus and concern and discovering what is important to the patient and family. It also requires knowledge of self, for understanding ourselves and our emotional responses to things that happen with our patients and in our unit. It requires recognizing and being able to manage our own personal stresses. It also requires us to have good working relationships with other members of the health care team so that we are working together for the good of the patient.


Our relationships with patients and families are based on caring for them, contributing to their health, recovery from illness, or supporting them in death. This requires a therapeutic relationship that supports the patient and the family.1 A therapeutic relationship is different from a social relationship; it is designed to meet the needs of the client rather than meeting mutual needs. It is time-limited and based on nursing professional knowledge, commitment, and genuine concern for the patient and the family.2 It enables the nurse to provide physical, emotional, and spiritual care that benefits the patient and provides professional satisfaction to the nurse.2 Part of relationship-based care is recognizing the difference in a therapeutic relationship and a personal relationship, and being able to put the needs of the patient and family ahead of our own needs. In the NICU, because many of our patients and families are in our care for a long period of time, the boundaries sometimes become blurred if we are not paying attention to our own self and our emotional responses to our work.


We live in a society where social boundaries easily become blurred and unclear. Television shows encourage participants to discuss their deepest and most personal issues in front of an audience, to be critiqued and examined. We follow celebrities as if we know them personally and avidly watch every aspect of their lives, particularly if they are clearly in the midst of desperately personal problems. We are friends with perfect strangers on social media sites and freely share personal pictures and details of our own lives. Lines between personal and professional lives become blurred as well, and a seemingly casual comment about a work-related issue can be quickly disseminated to multitudes of people who were not the original intended audience. From there, they can easily take on a life of their own.


Florence Nightingale first addressed the idea of nursing boundaries built into the therapeutic relationship between nurse and patient.3 The Nightingale pledge refers to professional expectations like keeping confidences, maintaining standards, and abstaining from deleterious and mischievous behavior. These relationships are guided by a professional code of ethics that safeguard the patient and the professional, while maintaining a therapeutic and professional relationship. The American Nurses Association, in the code of ethics, outlines professional boundaries as "establishing appropriate limits to relationships."4(p151) The intimate nature of nursing means that the potential for blurring of these relationship boundaries is high and it is the responsibility of the nurse to maintain these boundaries.4 Because patients are in a vulnerable place, they cannot be held accountable for keeping the appropriate distance. There is a power difference, due to the nurse's professional knowledge and the intimate nature of nursing care. This is why engaging in personal relationships with patients or a former patient is discouraged.5 Medical professionals must be careful about forming "dual relationships" where patient and professional privacy may be put at risk.5 Nurses must be aware that the balance of power is not equal in these types of relationships and that the therapeutic, professional relationship can be damaged. In addition, extending the professional relationship to a personal one can lead to an excess of time outside of work devoted to providing support, advice, caretaking, and role confusion that leads to exhaustion, feelings of being overwhelmed, and burnout.


It was easier to set these limits in the day when forming a friendship actually meant you would have to exchange phone numbers or addresses. Now many of us, and our patients and families, can be easily found on a social media network such as Facebook. Consequently, we may be contacted by patients or families wanting to establish a relationship outside the professional arena. When caught unawares, we may be opening ourselves to a friendship that is not beneficial to the patient or to the professional.


Becoming "friends" on a social networking site such as Facebook means that individuals have access to a variety of personal information that you might not otherwise share in a professional relationship. Hobbies, relationships, lifestyles, and political views might now be viewed and become potential areas for disagreement or disapproval.6 You may find out things about the patient or family that they did not intend you to know. Suppose that you find out something that raises a concern for your patient's well-being? You then are in a position of figuring out what to do with that information. Or, suppose that your patient discovers something about you that you would rather they not know. Conversations that start out innocent with a family may inadvertently lead to privacy issues as that information becomes available to a multitude of other people.


So, how to manage those invitations to be friends? As a rule, it is best to avoid immediately accepting an invitation from a patient to be a "friend." If you are consistent, it is easy to say that as a professional you have to avoid such interactions.5 Be careful about what you disclose yourself on social networking sites. You never know who is "friends" with who, and what someone else might reveal. Use privacy settings to limit what information is shared with others. Most of all, think about what therapeutic relationships mean and how you can be in a relationship with patients and families that meets their needs, is professionally satisfying for you, and maintains professional boundaries.




1. Gamez GG The nurse-patient relationship as a caring relationship. Nurs Sci Q. 2009;22:126-127. [Context Link]


2. O'Connell E Therapeutic relationships in critical care nursing: a reflection on practice. Nurs Crit Care. 2008;13:138-143. [Context Link]


3. Holder KV, Schenthal SJ Watch your step: nursing and professional boundaries. Nurs Manag. 2007;38(2):24-29. [Context Link]


4. American Nurses Association. Guide to the Code of Ethics for Nurses. Interpretation and Application. Silver Spring, MD: American Nurses Association; 2010. [Context Link]


5. Guseh JS, Brendel RW, Brendal DH Medical professionalism in the age of online social networking. J Med Eth. 2009;35:584-586. [Context Link]


6. McBride D, Cohen E Misuse of social networking may have ethical implications for nurses. ONS Connect. 2009;24(7):17. [Context Link]