Some patients with cancer will not survive. Death may be a reality, but that does not make it any easier for oncology healthcare professionals. We work hard alongside patients and their caregivers to fight this ugly disease. We witness each patient’s extraordinary courage and determination, especially in areas like phase I/II clinical trial centers or hematopoietic cell transplant (HCT) programs. Oncology nurses, in particular, develop close personal relationships with their patients. We genuinely care, which makes us very good at our jobs. Yet, these same feelings cause many of us to truly grieve a loss.

After a patient’s death, some nurses consider attending their viewing, memorial service, or celebration of life. There aren’t black-and-white answers or hard rules about this; each situation is unique. But before attending, ask these critical questions:

Will I go to services for all of my patients or just those with whom I formed a special bond?

I vividly recall the only funeral I attended in my 33-year career as an oncology nurse. The patient had a difficult death. She had been on a ventilator for days before finally losing her 7-year battle with chronic graft-versus-host disease resulting from an unrelated allogeneic HCT. We met when she was admitted for her transplant. Over the years, I helped her during her numerous hospitalizations and outpatient clinic visits. I even helped train her homecare nurses. I had a special bond from the long-term relationship with her and husband. I drove to her funeral alone, but soon found other transplant team members. I didn’t think about why I wanted to be there; I simply went. Maybe I looked for a way to say goodbye or have closure. Perhaps I needed to let the family know that I cared and grieved, too. But I was not able to communicate anything. I emotionally fell apart. Her oncologist ended up comforting me, instead of me being able to offer condolences. —ED

The death of a patient can be very emotional, and yes, oncology nurses need to grieve. But a patient’s funeral is often not the best place to process personal feelings or to debrief. It’s also important to remember that confidentiality laws apply even after a patient’s death.

While some family members may welcome attendance, others may find it a reminder of unhappier times. Nurses should not place the family in a situation of feeling that they need to care for the nurse.

Some institutions offer onsite memorial services, especially for families of international patients. This can be tricky, as someone needs to provide patient care, but what if there is a service and no one goes except for the family?

Certain managers may view attending services as “crossing the line” of professional behavior. While others may not encourage it, they recognize that it is an employee’s choice of how to use their personal time. Some hospice services support, even require, staff attendance at funerals or memorial services as part of bereavement care. Be sure to not only check the manager’s philosophy but employer policies, too.

Think about attending work-sponsored grief support. Sharing with co-workers who are in your same situation can be very helpful. Some facilities provide staff the opportunity to attend scheduled remembrance services (monthly, quarterly, or annually). Others offer debriefing sessions or moments of silence to come together to reflect on patient deaths. A bereavement coordinator may be designated to ensure the session occurs in a timely manner, often that very same day or the day after a patient’s death.

Consider having team discussions, in advance, of how your work setting will best handle a patient’s death; these must be in line with organizational policy. Suggest to leadership, social work, and spiritual leaders ideas or strategies that would be most helpful for patients’ families and staff. A healthy supportive work environment is critical to nurses’ health and well-being.

Being equipped with the tools and resources to deal with grief may lead to decreased compassion fatigue and burnout.

In order to be sustainable in the field of oncology, nurses need to focus on self-care and make maintaining physical, emotional, and spiritual health a priority. Every nurse must decide whether that includes going to a patient’s funeral or memorial service. Think about attending the memorial service, if there is one, instead of the funeral. It is often more informal, where people come and go at any time. Try to find a colleague and share a ride.

There are other ways to honor a patient’s memory besides attending the funeral. I often donate to a cancer charity that fits the patient’s diagnosis or personality. I recently contributed to an organization that uses musical events to raise cancer awareness and funding to honor the loss of someone who loved music and sang in the choir. I typically send a card to the family or post on the online funeral home memorial site.

Some nurses may journal what they learned or will remember most from this patient. Others choose to meet to share memories with other staff and each other, either formally or informally.

Articles

Consider the family's feelings and check workplace policies when determining how best to share condolences and cope with your grief.

Is It OK for an Oncology Nurse to Attend a Patient's Funeral?

Oncology nurses should aspire to give care that goes above and beyond what is necessary to assure the safety and wellbeing of their patients. They are charged with reducing the suffering of patients with cancer but also should do what they can to ensure a positive patient experience. Today’s healthcare environment is competitive, and, practically speaking, care is partially judged by patient satisfaction.

There is, however, a gray area between what qualifies as excellent professional care and what crosses the line into inappropriate behavior. Is doing a favor for a patient simply providing excellent care? What determines if a favor is reasonable? Ask these 3 bottom-line questions. Is the behavior:

The first 2 questions may be easier to answer, but the last can be tougher. It might help to consider if the action could be done for any patient. The real-world scenarios below might also help guide you.

Martin is on the inpatient oncology unit on bed rest, with only bathroom privileges. He asks if anyone going downstairs would be willing to buy him a couple of magazines using his money. As his nurse, you agree to do so.

The exchange of money between a patient and healthcare professional can be tricky and could become a he said/she said situation. Having someone witness when the patient gives money to the nurse and providing the patient with the receipt helps protect staff. Consider contacting volunteer services, which may offer reading materials, lending libraries, or humor and art carts.

The next day, Sarah, another patient on the same unit, learns that Martin had staff get him some magazines. She asks if someone could pick her up some chips. Your colleague who is caring for her states, “Sorry, I can’t do personal favors for patients.” Now Sarah thinks that Martin got special treatment.

It is not that one nurse was right and the other wrong—different nurses have different boundaries regarding personal versus professional behavior. In this situation, the action was not illegal or unsafe but might be considered outside the scope of professional care.

John finishes a treatment in the outpatient infusion area and learns that his ride can’t pick him up after all. He asks his nurse if the cancer center volunteer could give him a lift just this once. She lives about 10 minutes from his house, and they have formed a special relationship.

Hallie comes alone to the same cancer center because her family members are day laborers—if they  do not work, they do not get paid. This rural area has no mass transit, ride-share, or taxi service. The nurse navigator usually offers her a ride home because Hallie lives along her commute.

John asks a favor of a volunteer (just this once); Hallie's nurse navigator offers (frequently) to give her a ride home. Is there a difference in policy or guidelines for a volunteer versus an employee? Is the situation different if the patient asks for a favor versus a nurse offers it? Does it matter if a favor occurs once versus all the time?

Although these situations differ slightly, the main concern is the same—safety. Suppose there was a car  accident or the patient fell while walking from the car. Who would be liable? This behavior most likely violates the employer policy for both the employee and the volunteer. Employee guidelines usually apply to volunteers, who are considered an extension of hospital staff and follow the same privacy and safety rules.

If a ride is given 1 time, the patient (and probably coworkers) might expect it again. When other patients hear about it, the situation may escalate to where many patients assume that staff can provide  transportation services. Bring the matter to management’s attention so that a proactive plan can be put in place for these situations.

Mariana’s fluorouracil pump is due to be disconnected Thursday afternoon. Her daughter, who usually drives her, unexpectedly had a work situation she could not get out of come up, and Mariana has no way to get to the office. If her pump is not disconnected, the alarm will go off and might upset her. One of the infusion nurses realizes that Mariana lives in an area that’s on her commute, so she stops at Mariana’s home, disconnects the pump, flushes the line, and brings the pump back to the office.

This action is likely unsafe and possibly illegal. Providing home care is likely outside the scope of practice of an outpatient infusion nurse. If something were to happen, the nurse—and potentially her employer&mdash;could be held liable, since this is a patient under their care. Alternative solutions include coaching Mariana over the phone about how to turn off the pump or seeing if a home care nurse could help.

Rajesh is a patient with end-stage disease and not yet on hospice. He has run out of his narcotic analgesic. He lives alone and is unable to come to the office, but if his meds are not refilled, he will  begin to have a great deal of pain. His office nurse asks his physician to write a script, which she delivers to Rajesh on her way home from work. His sister will be able to take it to the pharmacy the next day.

Although this may not be illegal, unsafe, or unprofessional, the issue is that it cannot be done for everyone. What if another patient learns that a prescription was delivered? Could delivery become an expectation or seem like favoritism? Alternative solutions include calling in the prescription to a pharmacy that delivers or connecting with a volunteer organization that serves Rajesh’s community.

Helping in a personal relationship is very different from in a therapeutic, professional relationship. Knowing the differences can promote early recognition of a potential boundary crossing and prevent workplace conflicts.

Before doing a favor, quickly reflect on its consequences and impact. Think through potential perceptions from all sides—patients, colleagues, managers, employer. Consult with trusted colleagues. Consider contacting a manager to make sure actions align with employer guidelines. Favors may be done with good intentions but backfire if the behavior is illegal, unsafe, or unprofessional.

Sometimes oncology nurses get into sticky situations with favors because they try to do everything themselves, but that can cause the nurse to have feelings of inadequacy that can lead to moral distress, compassion fatigue, and burnout. Reach out to social work, volunteer services, management, or other team members to explore potential resources or help brainstorm possible solutions.

Navigating the gray area between excellent professional care and inappropriate behavior can be difficult.

Doing Favors for Patients

Playing favorites occurs in many aspects of life. Children often accuse their parents of it; in the workforce, a boss might be perceived as giving a better assignment to a certain worker over another. Favoritism, which is defined as favoring 1 person or group over others with equal claim, also exists in the medical field, with healthcare providers having favorite patients.

Favoritism can be conscious or unconscious behavior. It can breed resentment and negative feelings among patients and colleagues, and it may even be a form of discrimination.

The National Council of State Boards of Nursing identifies favoritism as an early warning sign of a boundary crossing. The concern is that some patients may be treated differently or better than others. Favoritism can be a sign of overinvolve&shy;ment and straying outside the “zone of helpfulness” of a thera&shy;peutic relationship.

Amanda, a 38-year-old onocology nurse,reflected back on her early years as an oncology research nurse and her favorite patient. Jane, a Baptist missionary, had metastatic melanoma and was participating in a phase I/II clinical trial. Her husband, Ron, had just finished treatment for renal cell carcinoma when she learned of her diagnosis. They had 5 adult children who lived all over the United States but nowhere near the treatment center.

“I instantly bonded with her,” Amanda recalled. “I could relate to her values and beliefs; in fact, we discovered we knew some of the same people at my church. I felt terrible that she had not recovered from her husband’s cancer only to find out she had cancer."

Although their children were supportive, this couple’s life was now in the Philippines as missionaries.

“I spent hours just sitting with her during stem cell collection for a research trial,” Amanda continued. “I found myself wanting to solve all her problems and continued to help her via email, even after she left the cancer center. I know I gave her preferential treatment and went outside my boundaries as a nurse."

Why nurses may like or dislike some patients, as well as how those feelings affect nursing care, has not received great atten&shy;tion in nursing literature. But a qualitative study conducted by researchers from the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, examined the physician—patient relationship. Many primary care physicians stated that although they try to treat all patients equally, favorites often receive extra or more timely care. One physician admitted that favorite patients “probably hear back more rapidly than less favorite patients.” That mind-set can be picked up by a patient who then tries to become a “favorite” to get better treatment.

Long before I learned about professional boundaries, I fell prey to this thinking, too. For instance, when my family members were in the hospital, I always made sure they had a bowl full of candy to offer staff.

What factors may cause us to favor—or want to avoid&mdash;some patients more than others? Below are some that I explored:

First, nurses must acknowledge that they are simply going to like and dislike some patients. It’s human nature. Patients who have an engaging, captivating person&shy;ality or hold similar values or beliefs may be easier to like or relate to.

When nurses see a need, they try to meet it. Often, nurses act without thinking about downstream effects.

Nurses can feel close to patients, especially those who are very sick or whom they have known for a long time. That patient often becomes one of the favorites.

This psychological term describes how past feelings, conflicts, and attitudes can affect present relation&shy;ships, situations, and circumstances. For example, a patient who sees a nurse more as a nurturing mother or father figure can become less independent or even childlike. This may cause a nurse to treat that patient differently or do more for them.

 With this form of transference, the nurse’s reaction to a patient may affect care. A patient may remind the nurse of a favorite uncle or crit&shy;ical father, which can positively or nega&shy;tively affect the care a patient receives.

This label often describes a patient who is considered challenging or high maintenance—someone who is angry, nonadherent, demanding, never satisfied, or highly critical. Difficult patients may cause nurses to feel ineffective or incompe&shy;tent, frustrated, or even exasperated. Nurses may start to distance them&shy;selves or become underinvolved, which is also considered a boundary crossing because it is outside the “zone of helpfulness.”

A patient who is considered easy (eg, is especially nice, has good veins, requires simple treatment, or expresses gratitude) tends to become a favorite. Nurses may find themselves wanting to be associated with those kinds of patients, spending more time with them or doing favors for them.

Some nurses may at some point err on the side of being overly invested with certain patients, perhaps early on in their career (like Amanda). It is important to remember that this naturally occurs in human bonding. Anne Devine, MA, BSN, a nurse turned writer, wrote about this subject, stating, “Sometimes nurses sense a connection with a patient that we don’t fully understand in the moment.” Although she tried to make every patient feel special, she said, some became her favorites.

Oncology nurses should realize that they are not alone in their quest for the perfect balance of nurturing/caring and professionalism. They have a responsibility to ensure that all patients with cancer receive the same quality of care. With an emphasis on cancer disparity, it is even more important to be aware of favoritism and its impact. Nurses who do so will be better equipped to stay inside the boundary lines.

Patient favoritism crosses boundaries. Why do nurses often breach this professional barrier?

Raising a Red Flag: Patient Favoritism

®, we explored the question, “Do you or don’t you accept a gift from a patient?” The short answer was “maybe.” Small token gifts may be acceptable, but what about giving a patient a present, either bought or handmade? That gets more complicated.

Our instinct as nurses is that when we see a need, we want to fulfill it. We simply desire to fix things for our patients or show a little kindness. For example, suppose your patient who knits needs more yarn to keep occu&shy;pied during treatment; another is short of cash for a bus, taxi, or ride share; or a strapped care&shy;giver craves a gourmet coffee. You happen to have cash and can easily meet this need.

However, using your own money or even lending your belongings can not only violate a professional boundary but also may be illegal. Even a small pur&shy;chase can cause significant legal implications, because it can be seen as inducement. Laws prohibit individuals and healthcare organizations from purchasing anything that persuades or influences a patient’s healthcare. What we think of as kindness may be viewed as a type of kickback or incentive. Today’s regulatory environment is complex.

Often, the social work team or care coordina&shy;tors and navigators work behind the scenes to help coordinate appropriate resources for all those in need. Many facilities have a patient assistance or petty cash fund to provide immediate help. But if not properly coordinated, it may be viewed as unfair or unequal treatment.

As nurses, we sometimes confuse giving some&shy;thing to patients with providing extraordinary care. Think of the countless ways you can go the extra mile that do not involve buying something or personal spending for care.

So, what do you do if you see an unmet need or want to give a gift? First, ask yourself these questions:

Would giving the gift change my professional ther&shy;apeutic relationship (outside the zone of helpful&shy;ness) with this patient or any of my other patients?

At what point do I draw the line to meet my patient’s needs?

Could the gift be viewed by others as inducement? Could it cause me or my organization harm?

What happens if another patient realizes that I provided something for someone else but I am not providing it for them?

Will I inadvertently create a difficult dynamic with team members who have a different set of bound&shy;aries and don’t use their own money? Could this alter my relationship with my colleagues?

Would the patient or their caregivers feel the need to give or do something in return?

What do my organizational policies or profes&shy;sional standards say?

Next, talk with your social work team, naviga&shy;tors, or manager. If you see a recurring need, con&shy;tact your manager to become part of the solution for all patients, not just the one you are caring for that day.

Consider the following real-life example: One metroplex clinic treating uninsured patients with cancer found that many of their patients did not have sneakers, so they could not participate in their survivorship exercise program. By partnering with a local professional organization and a sporting goods store, they continuously collect financial donations to provide shoes for those in need.

As a seasoned oncology nurse, I have seen the struggles of many patients with cancer and their families. And yes, I have been tempted to sim&shy;ply share my many blessings—money, items, and time on my day off. Personally, if I did that for one, I would need to do it for all. I decided early in my career that my gift to my patients would be that I would be the best oncology nurse possible

A nurse examines whether using her own money to fulfill a need crosses a professional boundary

Giving Gifts to Patients: Acceptable or Unacceptable?

Social media has become a way of life. Posts, tweets, videos—these are ways in which many people now communicate with one another. I especially know how ingrained it is in our lives, as I have a teenage son who can barely live without his smartphone during mealtime.

Social media refers to any Web-based or mobile technology such as Facebook, YouTube, Instagram, Vimeo, LinkedIn, Twitter, and CaringBridge.

As we explore common boundary crossings, we delve into the blurred world of social media. In the past issue, we defined a professional boundary crossing as a “brief excursion across professional lines of behavior.” Boundary crossings can not only damage relationships but also lead to negative outcomes.

It’s only natural that patients or caregivers will reach out to their oncology nurses through social media. And this is where oncology nurses can unintentionally blur the lines between professional and personal lives.

Think about the effects of being friends with patients or their caregivers on Facebook. You have access to all personal and family information, which creates more of a personal relationship than a professional, therapeutic one. For many reasons, you would never be the nurse assigned to care for a family member. It’s too easy to lose your objectivity. When you move toward a personal relationship or friendship with your patients or their caregivers, the same issues of objectivity arise.

Use of social media can easily violate patient confidentiality. The National Council of State Boards of Nursing (NCSBN) social media guidelines state that “it is imperative not to mention patients by name or provide any information or details that could possibly identify them in order to protect patients’ right to privacy.” Nurses have a legal and ethical responsibility to maintain patient privacy and confidentiality.

Disclosure is often unintentional. Your posts are not private. Someone can simply take a screenshot of the information and send it on or upload it to the Internet. Posts never truly disappear. Even if a post is deleted, it lives somewhere on a server that can be discovered in a court of law.

To protect your nursing license, consider the downstream legal effects.

Examine how this content might be viewed by others in the following posts:

WHAT IF…a patient posts that she had a great weekend with family visiting but is now feeling really tired. Is the fatigue from overactivity or related to anemia or even a sign of recurrence? Are you legally obligated to report if you see something about her health that is concerning? What if it’s a behavior that could pose a health risk? For instance, she posts a picture of herself drinking wine when you know she is on medication that should not be taken with alcohol.

The challenge with this scenario is to know your legal and ethical responsibilities. Now that you have this piece of information, what do you do with it?

WHAT IF…your former stem cell transplant patient, who almost didn’t live, comes back to your inpatient unit to celebrate his transplant anniversary with his nurses. You take a picture of him with your colleagues and post it with the caption “This is why I became a nurse.”

This scenario could result in a HIPAA violation and disciplinary action by the Board of Nursing as well as your employer. Most organizations have guidelines about taking photos of any person who works in their facility or who received any services.

A written formal consent for photos is usually required, and it needs to be obtained from everyone in the photo. So another patient in the background of the photo or a pictured arm with a tattoo that could be even remotely linked to another patient could create a messy legal situation.

WHAT IF…you’re simply sharing about your day with a colleague. You mention in your post that you went to the coffee shop and bought coffee for two of your patients. No names mentioned, no photos, no negative comments…No violation, right? What’s the problem? Although your gesture was one of kindness for your patients, using your personal money to buy items for a patient can cause feelings of unequal care and unrealistic expectations for your colleagues.

Can you do this for all your patients? Does this post have the potential to impair your work relationships?

So how do you avoid potential boundary crossings on social media? Below are 2 action steps:

1. Politely decline friend requests. If a patient or caregiver finds you on Facebook and sends you a friend request (even if the patient has returned to the care of the referring provider), politely decline the request. Tell them that your institution has strict policies regarding social media, so you have to respectfully decline their request. Most do. If not, the NCSBN and the American Nurses Association (ANA) do.

2. Unfriend current patients/caregivers. If you are already using social media to communicate with patients and caregivers and the site is not work related, consider letting them know that you will be unfriending them. Tell them that you realize there could be a perception of a conflict or a blur between your personal and professional lives.

Importantly, find out whether there is a policy on social media where you work and then review it. If there isn’t, consider being on the team to help develop one. Read the NCSBN and ANA guides to social media and know what your particular state advises. Not only do these guidelines apply to your current role, but they can also affect your reputation for any potential future employment or educational institution admission.

Use of social media can easily violate patient confidentiality.

What to Do When Social Media Lines Are Blurred

Perhaps when you read the title, your first thought was, “Oh great. Someone is going to tell me what I can and cannot do in my nursing practice.” As oncology nurses, we realize that if we do not have borders or “boundaries” for the care that we provide, it can be harmful to our patients, our coworkers, our organization, and us. Sometimes, however, a particularly special patient can tempt us to push or break our boundaries.

As a nurse who has worked in oncology my entire career and lost both of my parents to cancer, I can tell you that oncology is very rewarding. But it can also have its pitfalls. There are times (or will be times) when you become overinvolved and even underinvolved. Your goal is to remain in what is described as a zone of helpfulness that allows for a professional, therapeutic relationship to help meet the health needs of those under your care.

Your knowledge and skills as an oncology nurse, as well as access to confidential information, make the patient vulnerable and give you power. You might not like the word power, but it is real because you control the care you provide, you have access to private and personal information, and you have specialized knowledge about cancer and its treatment.

The National Council of State Boards of Nursing defines a boundary crossing as a “brief excursion across professional lines of behavior.” Your action may be unplanned and honestly intended to meet a patient’s or a caregiver’s need. Consider the following:

It seems like a harmless, kind gesture. But questions to ask yourself are:

1. Are there any real or perceived issues?

2. Can you reasonably do this for all the patients in your care?

3. How will your action affect your coworkers?

Often we do not think about the downstream effects of our actions or how others might view them. We simply see a need and have an answer to how to meet that need. Your good intentions are not always in the best interests of the patient, the caregivers, your coworkers, or the organization.

At first, you may conclude that there is really no issue with this scenario. After all, it is just a small, kind thing you can do for your patient, right? You may also think that it could just remain a “secret” and that your coworkers will not know. Or you may not care if you are viewed as the patient’s “favorite” or “special” nurse. The problem is that one small gesture can lead to another and another—and possibly a boundary violation. It is also a possibility that this kindness can have repercussions by itself&mdash;the patient may start demanding you as a nurse or being dependent on you.

Boundary violations are potentially harmful actions that violate your professional relationship with patients. The most obvious violation is any sexual involvement with a patient. Boundary violations are often clear-cut, with damaging results. Boundary crossings, however, can be blurry, requiring your professional judgment and perhaps the professional advice of others.

So, what is the harm of a boundary crossing? A boundary crossing can damage your relationship with your patient, cause potential harm to other patients, put your colleagues in difficult situations, and cause unintentional risk for your employer. Small multiple boundary crossings can lead to a boundary violation, which can have legal consequences or loss of your hard-earned license.

Crossing boundaries can also affect you personally. Without clear boundaries, nurses have higher burnout, turnover, compassion fatigue, and moral distress and may even experience negative mental health issues like posttraumatic stress disorder. Oncology nurses, particularly younger or novice nurses, are at higher risk for turnover (41%) compared with other specialties (13%). So, it is important to learn skills to prevent, recognize, and manage boundary crossings.

Over the next few issues, we are going to explore common boundary crossings such as social media requests, using your own funds, and transporting or housing patients and caregivers. We want to discuss your concerns and provide different ways to handle these issues.

Boundary crossings happen to every nurse, especially oncology nurses, who may be with their patients for an extended period of time and develop a special bond. Like cancer, the key is prevention! We want to help you recognize early warning signs, conduct self-evaluations, and more carefully consider what is in your patient’s, colleagues’, and organization’s best interests.

Warning signs can provide insight that you are sliding on the continuum outside the zone of helpfulness toward non-helpful behavior. You will learn what to do if you think you are close to crossing or if you see a colleague heading outside the therapeutic border. You will also learn how to recognize when you have crossed a border and develop strategies for getting yourself back on track.

Because we are most vulnerable to boundary crossings when we are not taking care of ourselves, or when we do not have a work/life balance, we also want to discuss self-care strategies. These strategies are important for any nurse but particularly oncology nurses because we need to prevent talented oncology nurses from burnout. The goal is to keep oncology nurses in oncology, where they can make the biggest impact.

Perhaps when you read the title, your first thought was, “Oh great. Someone is going to tell me what I can and cannot do in my nursing practice.”