HISTORICAL CASE STUDY #1: Misplaced Affection, Professional Responsibility
A state mental health facility suspended Ms. Priscilla Rothschild, a registered nurse, pending an investigation into allegations that she had a romantic relationship with a patient. A county recorder indicated that a marriage license named a patient, Mr. Benjamin Huntington, as the groom and Nurse Rothschild as the bride. Nurse Rothschild was permitted to resign from employment, and the situation was reported to the board of nursing.
Nurse Rothschild had worked in general adult psychiatric units throughout her career. She was licensed initially as a licensed practical nurse, then progressed to complete an associate degree in nursing. She obtained her license as a registered nurse in 1995. She had no previous history of employment discipline and no discipline history with the board of nursing.
Nurse Rothschild stated that the relationship with Mr. Huntington consisted of “making popcorn, playing pool, and playing cards.” She said she was vulnerable because her common-law husband had deserted her. Mr. Huntington told her that once he got out of the hospital he would be the loving, most wonderful husband she never had. Mr. Huntington reportedly talked her into getting married and convinced her that she could ask the newspaper not to publish the marriage license. Nurse Rothschild reported that she purchased a marriage license for herself and Mr. Huntington.
Nurse Rothschild maintained there was no physical contact between Mr. Huntington and her. She said she knew there was a policy about boundaries, but she was never oriented to it. She had never received any special training for working on the forensics unit even though she had been working there a year.
Nurse Rothschild indicated that she had begun intense psychotherapy and maintained that she was not terminated from her employment, stating, “…I chose to resign.” She said she intended to continue her relationship with Mr. Huntington who remained in the facility as a patient. She had sent him care/food packages and indicated that she wanted to visit him at the psychiatric hospital.
The investigation included interviews with other staff members who revealed that Nurse Rothschild had worked for 8 years on the general adult psychiatric unit. She requested transfer to the forensic division after a patient injured her, an incident she attributed to poor staffing. Nurse Rothschild was unable to work for several weeks after her injury and was afraid to return to her previous unit. She thought she would be safer on the forensic unit because it had more staff, including more male staff members working there. The following elements are noted:
1Nurse Rothschild said she came to understand that having a personal relationship with a patient was wrong and that she didn’t understand why she and others engage in personal relationships with patients.
2Nurse Rothschild became attracted to Mr. Huntington when she observed other staff providing him “incompetent care.” She noted that Mr. Huntington had multiple medical problems and that she had a strong medical-surgical background.
3Mr. Huntington complained constantly of pain, especially migraines. He had filed grievances against staff, and many people lost their jobs.
4In one instance, Nurse Rothschild discovered that a staff member had removed Mr. Huntington’s catheter without deflating the balloon. She began to wonder if his complaints could be valid, and began to advocate for him, but felt the staff was not willing to change because they “did not like him.”
5Nurse Rothschild said she initially denied having a personal relationship with Mr. Huntington because she wanted to protect her mother.
6Nurse Rothschild was transferred to a women’s unit when the marriage license was published.
7Nurse Rothschild would not make a commitment to her chief nurse that she would not contact Mr. Huntington or allow him to contact her.
8Nurse Rothschild resigned because she was embarrassed and wanted to continue to see Mr. Huntington.
9Nurse Rothschild was attracted to Mr. Huntington “because he didn’t turn on me.” However, Nurse Rothschild had become afraid that Mr. Huntington would “turn on her” and ruin her mother’s reputation. She thought Mr. Huntington loved her but that he would “retaliate.”
10Nurse Rothschild continued to visit Mr. Huntington twice a week. She said that the staff approved the continued contact since she was no longer employed there and that she met with his team leader and psychiatrist to assist them by encouraging Mr. Huntington to comply with his treatment plan so he could be discharged eventually.
11Nurse Rothschild said she had no plans to marry Mr. Huntington but could not terminate the relationship because she was lonely.
12Nurse Rothschild said that she had never read Mr. Huntington’s chart, did not perceive him as having a psychiatric diagnosis, and she was unfamiliar with Axis II diagnosis.
1 Mr. Huntington stated that he was romantically involved with Nurse Rothschild but not while she was employed as his nurse.
2 Mr. Huntington indicated that he has no complaints about her and did not believe that she interfered with his therapy.
3 Mr. Huntington wanted to continue the relationship with Nurse Rothschild.
CASE ANALYSIS AND RESOLUTION
Assessment of Care. This situation is characterized as a single, ongoing incident.
Causes. The causes identified in this case are knowledge deficits and errors of judgment.
Awareness. During her interview with the board of nursing, Nurse Rothschild seemed unaware that she had crossed therapeutic boundaries with her patient, and she did not want to end the relationship. Nurse Rothschild said that she left the facility because she was embarrassed. She reported that she was still seeing Mr. Huntington because she feared his retaliation and because she was either unable or unwilling to develop a plan to disengage from the relationship. This was because she said she needed to feel loved.
Responsibility. The responsibility in this case resided in primarily in Nurse Rothschild.
Evidence. Records support and Nurse Rothschild acknowledges having a romantic relationship with a patient.
Outcome/Patient Harm. No harm was assessed in this case.
Remediation Efforts. Nurse Rothschild secured employment at a long-term care facility. She did not plan to return to psychiatric nursing. She was seeing a psychologist because she said, “I want to find out how this could happen to me.” Nurse Rothschild characterized herself as having problems setting boundaries, but she said she saw herself as helpless and unable to change.
Legal/Ethical. Nurse Rothschild, indeed, was unable to maintain therapeutic boundaries. However, it remains unclear if she has the knowledge, judgment, and ability to practice forensic psychiatric nursing in the future.
System Issue. In this case, system controls were determined to be lax.
Proposed Resolutions. A stipulation was that Nurse Rothschild participate in the state’s Nurse Health Program (NHP).
Violation. The violation in Nurse Rothschild’s case was C.R.S. §12-38-117 (1) (f) and (j). It was documented that she:
(f) Has negligently or willfully practiced nursing in a manner which failed to meet generally accepted standards for such nursing practice; and
(j) Had a physical or mental disability which renders her unable to practice nursing with reasonable skill and safety to the patients and which may endanger the health or safety of persons under her care.
Administrative Process. This case was handled through an Alternative Complaint Resolution process. A stipulation and order were agreed on whereby Nurse Rothschild requested and the state board of nursing granted permission to enter the board’s confidential impaired professional diversion program in the state.
Action Taken. The following provisions were included in the order:
1That the state’s NHP would report to the board if Nurse Rothschild was terminated from the program for any reason other than successful completion.
2That if the state’s NHP ceases to exist, Nurse Rothschild would be placed on probation with the same requirements as set forth in her state NHP contract.
Disposition. Nurse Rothshild entered the state’s NHP and the state board of nursing took no further disciplinary action.
Case Analysis. The registered nurse did not seem to grasp the boundary issue in which she had become involved. She said that since she did not have a physical relationship with the patient while she was employed by the hospital, she did nothing wrong. She had no awareness that she stepped beyond the nurse/client relationship.
The registered nurse showed remorse that the incident reached disciplinary proportions but said she does not regret her relationship with the patient. She said that she had not interfered with the patient’s therapy and she intended to pursue the relationship.
The registered nurse perceived herself as a victim, as vulnerable. She did not acknowledge that the patient was being exploited. She did not understand that she was gratifying her personal goals instead of remaining on a professional level, serving the patient’s best interests.
The system issues in this case included laxity of procedures that may have promoted boundary problems; it did not seem to be unusual for nurses to socialize with patients/clients.
The system also did not provide this nurse with adequate orientation or education concerning the forensic field of practice and the need to respect boundaries of professional practice. Under the guise of patient advocacy, the nurse became overinvolved with the patient when she thought other staff members were neglecting his care.
System Recommendations. The institution was urged to:
1Institute policies and procedures to inform and educate staff about expectations regarding the staff-patient relationships.
2Expect all staff to promote and contribute to an organizational culture in which competence and professional ethics related to professional boundaries are valued and respected.
3Identify individuals who have had prior boundary issues through staff selection and hiring procedures.
4Orient and provide ongoing in-service education to address boundary issues.
5Offer approaches for identifying situations that could lead to boundary issues with an eye to prevention and for dealing with them when they do occur.
6Practice oversight and supervision to promote early identification and resolution of boundary problems.
7Review carefully allegations of boundary violations and take appropriate action when warranted.
8Provide support to staff through counseling, mentoring, discussion groups, and other methods to raise awareness regarding professional boundaries.