1. Wilson, Marian L. BA, RN

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I was about to lock the front door of the home health agency for the day when a nurse pulled up in a company car. She had been assigned only five home visits, yet she'd been gone all day. "Ms. Campbell is having such a problem with constipation," she reported. "So I ran to the drug store and got her some senna tea. It's really good, you know."


My job as director of a growing agency had become a scheduling nightmare. I needed nurses to be available to make unplanned visits, not tied up for two hours shopping for medicinal tea. I was also finding it increasingly difficult to please patients. Some would accept visits only from their favorite staff member, resulting in loss of revenue to the agency. It was a challenge, as well, to explain to Medicare why one patient, Peter Grey, required daily dressing changes, except during the two weeks when "his nurse" was on vacation.


I learned that some of the certified nursing assistants had been burdening patients with their problems. One took a shower at a patient's home. When I tried to explain the difference between a personal and a professional relationship, her anger flared. "You can't tell me who can be my friend! You've no right. I quit!" she snapped.


Sometimes, during my lunch hour, I visited Stella Gruner. She was number 0001, the first patient admitted to our agency two years earlier, and I had been her home health nurse. Now living in a nursing home, Stella greeted me as if I were a long-lost relative. She boasted to the staff that I was her nurse and I cringed, just a little. Others might find my visits inappropriate or question my motives. To them, I represented the competitive home health environment. Some agencies follow their patients, sending personnel to visit them in hospitals and nursing homes to prevent other agencies from taking over their cases. Were Stella and I friends? Or did I stay in touch with her in case she needed my agency's help again someday? Technically, my visits were neither professional nor personal, but something in between. Stella tugged at my heart and I felt drawn to her.


I lectured my staff members on the impropriety of letting patients depend on them for companionship. They needed to help patients connect with agencies or relatives, not fill the void themselves. "How will those patients feel when your job is done?" I asked. "How will they manage when you move on? Our duty is to promote independent, at-home living. Encouraging dependency, then leaving patients to fend for themselves after discharge, is not the service we're paid to provide." I knew I was trying to regulate something that isn't easily regulated. Each caregiver engages with patients in a unique way.


Stella was a storyteller, and I love stories. I knew how her husband had died suddenly of a heart attack, right after they moved from Louisiana to live with their son. I heard of her grandchildren's trials; one was in trouble with the law, another was looking for a suitable mate. When I was Stella's nurse, we had always dispatched the business of the visit quickly. Then she'd insist that I have a piece of home-baked bread or a muffin. Once, she gave me a shoot from her aloe plant. Although I tried to refuse her gifts, Stella insisted.


At the office, a nurse had told me that his patient had offered to give him a shed full of wood. "I can really use it for building my birdhouses," the nurse explained. "What about his family?" I asked. "Maybe someone has an eye on that wood pile. How will they feel if you take it? They've known him all their lives; you've known him only a few months."


I prepared an inservice seminar to clarify our agency's policies on boundary issues. As I stood in front of the staff, reciting our rules against accepting gifts, I thought of the aloe shoot, now taking root and growing. I wondered if it's realistic to expect our responses to each patient to be identical. Is it wrong to play favorites?


I went to visit Stella again. She remembered each of my pets' names. Happy enough in her new home, she continued to attract everyone around her with her kindness. She'd been crowned queen at a Valentine's Day party and I wasn't surprised. Stella told me that her doctor brought her root beer floats when he made his rounds. When I saw a photo of him and his family at her bedside, I knew it wasn't just me who had been drawn outside professional boundary lines.


Missing the rewards of first-hand patient care, I left the home health business. After three years in a supervisory position, I was grateful to no longer be the one trying to monitor other people's relationships. Now, as a staff nurse on a hospital floor, things would be different-or so I thought. I saw nurses bring gifts to certain patients. Some gave their phone numbers to their favorites or came in on their days off to rub their patients' backs and feet. I wondered about our desire, as nurses, to be needed. I wondered how much our drive to be "the special one" determines what we do. Our vocation puts us in a position of power, which complicates things. Friendships with patients can never be an equal partnership.


I saw Stella, and she had changed her room. Every inch of her walls was covered with photos and cards. Many hung out of her view, above her head and all the way up to the ceiling. Lying flat on her back, she gestured to the wall and tried to tell me a story about a picture, but it made no sense. Her lips were cracked. White hair stretched in every direction. I reached to smooth it down. Stella said, "That feels nice, honey. Can you give me some cold water?"


An intravenous pump pushed fluid into her puffy hand. The machine read "continuous" in neon green. I brought a chair close to her bed. She hadn't been getting up much lately, she told me. Her name was printed in fancy script on a pink water pitcher. I filled a cup and held a straw to her lips. She asked me for a drink five or six times and I complied. She apologized for this demand. "You know, they're all so busy here. They can't always be here when you need something." I watched the clear liquid drain into the straw. Colorless, tasteless, and odorless, water seems like nothing at all, yet it's essential to life. I thought of the boundary issue as a body of water. You try to keep it contained and controlled, but even through the smallest crack in the dam or chip in the glass, it spreads wildly of its own accord. It's the unseen in our relationships that makes them meaningful. You can't regulate that.


Stella looked me in the eye and asked, "Do you think I'm gonna make it?" I didn't know if she was asking for my personal belief or for professional assessment. I had no information about her condition, yet she still regarded me as a nurse. Her nurse. I told her the truth. "I don't know." Our eyes filled with tears.


Some patients get into our hearts; some get under our skin. At times patients cross our boundaries, eliciting emotions that we try to keep in check. After 20 years of giving care, I still search for the boundary line that separates professional concern from unhealthy attachment. Regardless, my huge aloe plant has branched out from the tiniest of sprouts, a symbol of broken rules and spontaneous friendship.


Some patients get into our hearts; some get under our skin.