I started out with a simple assignment: to write about babies who spend time in our neonatal units awaiting adoption or foster placement, and what nurses can do to document those early days and weeks so that as the children grow they can have images and mementos of their infancy. What I found instead was a more complex story about how nursing sometimes fulfills roles usually reserved for families. As nurses, we all have patients whom we become close to, and because we care for children, we are especially vulnerable to this. We see children and their parents at the most difficult moments, sometimes for months on end. In nursing school we are taught about maintaining professional boundaries between ourselves and our patients and their families. But what do we do when patients have no one but the nursing staff to be their family?

Nancy Werner, RN, a staff nurse in ICC, is a 35-year nursing veteran. She describes herself as “almost evangelical” about maintaining professional boundaries. However, caring for “Mary” challenged those boundaries.

Mary’s medical situation was not so different from many other patients in the neonatal units. She had a complex illness involving a number of body systems. However, her situation was unique in two ways: her length of stay (more than a year) and her adoptive status. She had no involved parents at the time of her hospitalization, so Nancy, along with Mary’s other caregivers, filled the role of “seeing Mary as a whole person of value, not just the baby in room 21.” They needed to provide Mary with the nurturing, affection, and bonding she might not otherwise get. They hoped that in time, because they had given Mary these things, Mary would in turn be able to give them back to an adoptive family.

For months Mary’s medical situation was fragile at best. At times, it became so desperate that she needed intensive care. However, in talking with Nancy, I was impressed not only with how well Mary’s medical needs were met but how well her nurses maintained a sense of normalcy for her. For example, Nancy began a baby book and invited others to contribute stories and pictures. Although medical issues were mentioned, Nancy did not want it to become a book about broviacs and dressing changes, but rather a book that would celebrate Mary’s “humanity and babyness.” Eventually, the book contained anecdotes and stories about Mary’s life, poems, and pictures of Mary’s first holidays and her first birthday party. Nancy provided Mary with her first transitional objects: when Nancy realized that Mary was becoming attached to her “frog” positioning device, she brought her some stuffed animals that she could have for her own.

Around her first birthday, Mary began turning the corner and eventually was well enough to go home with a foster family. Since Mary’s discharge, Nancy has been able to see the many ways in which nursing care made a difference to Mary – a validation of her primary nurses providing bonding in a very intentional way. After Mary was placed in foster care, she immediately attached to her foster family. Within days they decided to adopt her - “a testament,” Nancy says, “to Mary’s personality.”

At one point after discharge, Mary did come back for a visit, and seemed not to remember her nurses. Nancy feels that Mary did this to protect herself and the new bonds she had forged with her parents. Nancy hoped that a time would come when Mary would feel secure enough within the bonds of her new family to be able to remember those who had cared for her as a newborn. That time came during an admission a year later when a sleepy Mary did recognize Nancy and nuzzled her as she had once done.

As I said at the beginning, I started out with a simple assignment and was led to a much richer story. Though most of us will not encounter a primary nursing relationship quite this complex, it does remind us how meaningful even the small things we do can be. Every footprint we stamp, every picture we take becomes a living memory of a child’s first moments – moments that adoptive families may have missed but will have keepsakes that will last forever.

Jennifer Rivera, RN, is a staff nurse in NICU.