Raising a Red Flag: Patient Favoritism

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 overinvolve­ment and straying outside the “zone of helpfulness” of a thera­peutic relationship.

Nurse-Patient Bonding

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 atten­tion 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—some patients more than others? Below are some that I explored:

• Personal element. 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 person­ality or hold similar values or beliefs may be easier to like or relate to.
• Tendency to to solve problems. When nurses see a need, they try to meet it. Often, nurses act without thinking about downstream effects.
• A special bond. 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.
• Transference. This psychological term describes how past feelings, conflicts, and attitudes can affect present relation­ships, 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.
• Countertransference. 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 crit­ical father, which can positively or nega­tively affect the care a patient receives.
• "Difficult" patient. 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 incompe­tent, frustrated, or even exasperated. Nurses may start to distance them­selves or become underinvolved, which is also considered a boundary crossing because it is outside the “zone of helpfulness.”
• "Easy" patient. 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.