At ANAC, Nurses Unpack the Importance of Emotional Intimacy in Providing High-Quality Care

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Nurses spend more time with patients than any other member of the care team does, forging strong bonds that can be an asset when advocating for a patient's care, and a burden when coping with emotional fatigue and burnout.

For infectious disease nurses who cared for patients in the 1980s, "the emotional link [with patients] was really born out of the fire of the early [AIDS] epidemic," said Ella P. Curry, Ph.D., M.T.S., RN, a nurse historian.

"Particularly in the early days, this job was high, high, high demand," said William Holzemer, Ph.D., RN, FAAN, dean and distinguished professor at the Rutgers School of Nursing in Newark, New Jersey. "The doctor walked in and maybe read the chart, said, 'Hi,' to the nurse, and said, 'Keep it up,' and walked out," said Holzemer.

"When I interviewed nurses from '81 to '87, one of the common themes was, 'in those years we had nothing to offer but ourselves,''' Curry said. "We were dealing with people who -- not only their bodies were failing, but more importantly, their hearts were broken." Curry said that in the face of discrimination and stigma, nurses resolved that patients "will know in our presence that they are people of worth," she said.

To this day, the intimacy between HIV nurses and their patients remains, according to nurses interviewed at the 2017 Association of Nurses in AIDS Care conference in Dallas. That special bond is universal to all disciplines of nursing, but within HIV, "it's intense in a different way," said Curry.

Intimacy as an Asset

"Nurses are 24/7 caregivers, so we are always there," said Curry. One of the assets of spending time with patients is that, by getting to know them better, nurses are able to make more nuanced decisions about their medical care.

For example, patients might share information with nurses that they don't tell their doctor -- either because of a lack of time or a desire not to burden the doctor with "non-medical" issues. Yet, some of these issues, such as depression, housing instability, or family strife, might severely impact a patient's ability to take medication every day.

"Nobody understands the patient like a nurse [does]," said Joseph De Santis, Ph.D., M.S.N., FAAN, associate professor at the University of Miami School of Nursing and Health Studies. "We spend the most time with them ...[;] we get patients when other people don't," he said.

In fact, intimacy is "one of the hallmarks of nursing," said Holzemer. It's the foundation on which good nurses can effectively deliver care, he said.

Related: "Caring at Its Essence": HIV Nurses Recall Pivotal Moments With Patients

Medical Translators

One of the more immediate and obvious ways nurses can wield intimacy as a tool is to act as a "medical translator" when patients have questions that they have been too shy or overwhelmed to ask a doctor.

When Curry worked as a nurse at Georgetown Hospital in Washington, D.C., she would often remind herself that when patients enter the hospital, "they're strangers in a strange land," and nurses are the people who help them navigate that strange land.

In fact, while working at Georgetown, she made a habit of making rounds twice -- an initial visit with the doctor and a second visit by herself. During that second visit, patients always had more questions or needed further explanation, she said.

For Curry, nurses are not only there to provide care 24/7, "but they're also the ones who can bring it home."

Avoiding Burnout

For Holzemer, the flipside of the emotional intimacy in HIV nursing is the potential for burnout. Curry noted that, in the early days of the epidemic, nurses would "go to battle with surgeons who [wouldn't] take our patients to surgery, dentists who [wouldn't] do dental care."

Stress in the nursing profession has been well documented. A 2014 study evaluating burnout among hospital nurses defined "burnout" as "long-term work stress resulting from the ... constant emotional pressure associated with intense interpersonal involvement[.]" And a 2015 abstract noted that in hospitals, "[t]he number of nurses suffering from burnout has increased over the years, possibly causing negative effects on patient care, working environments, and staffing shortages."

Although the acute stress of the AIDS crisis is over, nurses are still fierce patient advocates, sometimes without the power or clout to make their wishes heard.

"We're with the patients a lot more than anybody else [is]," said Bethsheba Johnson M.S.N., GNP-BC, AAHIVS, an associate director and HIV prevention medical scientist at Gilead Sciences, Inc., in Houston, who is currently pursuing a doctor of advanced nursing practice (D.N.P.), nurse executive track.

"We're advocating for the patient, and we get roadblocks ...[;] that frustrates me," Johnson said.

Emotional intimacy can take a toll, and it's important to be able to "put your own feelings away," said Theresa Minukas, B.S.N., a registered nurse at Massachusetts General Hospital in Boston. "At the end of the day, you become so emotionally attached and invested in these people and want them to do well[,] ... but [you also want] for you to make all the hard work pay off."

The bond nurses forge with patients can be "an overwhelming level of intimacy that happens instantly," Holzemer said. "Not just physically, but emotionally and intellectually. And it takes a damn smart nurse to deal with that."