The Art of Saying No: Setting Clinical Boundaries with Compassion

As a new nurse practitioner (or even a seasoned one!) you may have a hard time saying “no” to patients. As nurses, it’s in our nature to want to make our patients happy and healthy, but sometimes that means we need to tell them what they don’t want to hear. Saying no to patients can be as much about maintaining their safety as it is about maintaining professional and personal boundaries.

In this post, we’ll explore why setting boundaries is important, and what are some ways to say no while still fostering a therapeutic patient-clinician relationship.

Why Saying No Is Difficult as a Nurse Practitioner

If you’re like me, saying no isn’t something that comes naturally. That doesn’t mean you’re necessarily a people pleaser, but healthcare is a kind of service industry. We do get evaluated on patient satisfaction—and are constantly reminded of that! It’s totally normal to feel the pressure to make sure patients have the best experience and are satisfied with their care.

Also, patients are special to us, and we care about their feelings. So, it’s okay to have some negative feelings or inner turmoil about things like denying a patient something, like additional medication refills when they haven’t been seen in the office recently, or they want an antibiotic for a viral illness because they can’t afford to miss more work. Plus, sometimes it takes less time to approve certain administrative requests than to deny them, so that puts additional pressure on NPs to say yes.

But before we go any further, please remember: if you’re feeling pressured by a patient to say yes to an aspect of their care that is not legal, ethical, or professional, reach out to a colleague or supervisor. Your safety is most important. If you feel like a situation is escalating to an uncomfortable level, get yourself to a safe area and ask for help. 

Why Saying No Is Important

We understand that saying no is hard, but sometimes it’s necessary. As NPs, we practice at higher levels of care, decision-making, and responsibility. The previous examples demonstrate professional boundaries. Those align directly with the ethical principles we are guided to follow, like beneficence (do good) and nonmaleficence (do no harm). Let’s go through some more examples.

Unsafe or Unauthorized Prescription Requests

As advanced practice providers, we need to deny unsafe or unauthorized prescription requests. It can be difficult to hear a patient’s story about needing pain medication, an antibiotic, or a refill on a blood pressure medication—but they haven’t been evaluated in six months or more. Maybe they’re persistent about requesting lab work or diagnostic imaging that is not indicated. As nurses, we have a holistic view on medicine and we sympathize with our patients. However, the bottom line is: if it’s not safe, you need to say no.

Changing the Clinical Schedule

Another example could be a patient with a history of multiple “no-show” appointments and last minute cancellations, and then demands a same-day appointment for a non-urgent issue. That can be very frustrating. It may seem simpler just to allow the patient to be seen to avoid further conflict, but how does that affect the rest of the clinic schedule? Will it impact other patients who are more reliable and respectful of their appointment times? What additional stress or workload will that place on the staff to accommodate that patient’s request. As an NP, you have to have a wider view of the situation and assess multiple factors that can affect patient care.

Personal Boundaries

Besides the professional boundaries around patient care, there are also personal boundaries with your patients that you need to maintain. For example, the pervasiveness of social media means that many people have aspects of their lives online. This can be a great way to connect with others, but it can also create privacy issues. No matter where you practice, you may encounter patients “friending” you or following you on social media. It’s best to keep your profiles private and only allow individuals you know and trust to be able to view your full profile. Any communications with patients should be done through professional channels in your clinic organization. 

How You Can Say No Compassionately

Alright, so we gave some examples that demonstrated why boundaries and saying no sometimes are important. But how can you do that with compassion? Here are some great ways to start those conversations!

Sample Conversation Starters

Use empathy statements (validate the emotion).

“I can see this is important to you.” 

“I hear that you’re frustrated.”

Explain the “why” behind the boundary (“Here’s why I won’t do ______”).

“It’s not safe to….”

“There isn’t enough research and evidence to support…”

“Based on your symptoms and what I see on your exam, it does not warrant an antibiotic.”

“Our office policy is to…”

Offer alternatives.

“Although I will not prescribe ______, here are some options to try.”

“Let’s see when we can get you a timely appointment that accommodates both yours and my schedule.”

How to Use These in Clinical Practice

Now, let’s apply those tactics to specific scenarios:

When patients request antibiotics unnecessarily:

“Good news! You don’t need an antibiotic at this time. I understand you’re not feeling well, and it’s frustrating — so let’s talk about what will make you feel better.”

When patients ask for early refills:

“I can’t refill this medication early because it could be unsafe. Let’s talk about what’s been working and what hasn’t been and see if there’s another way to help manage your symptoms.”

When patients are not adhering to their allotted appointment time:

“I hear that you have a lot of concerns and questions today. I don’t want you to feel rushed, and I need to stay on schedule for my other patients. Let’s talk about one or two of your biggest concerns and then we can schedule a follow-up appointment to continue to address your needs.”

When patients expect after-hours communication:

“I hear your concern. Our policy is not to refill medications or prescribe or treat conditions over the phone. If you have a true medical emergency, you should seek care at the emergency department. Otherwise, I ask that you call during our regular business hours to make an appointment or talk with our nursing staff.”

When patients push against boundaries (social media, gifts, or personal questions):

“Thank you! I really appreciate the thought! However, I cannot accept the gift…”

Or, “I don’t share too much personally with patients…”

Or, “I have a rule to keep my professional boundaries consistent for all patients, so I don’t accept friend requests from patients — but your kindness means a lot.”

Final Thoughts

There’s so much more to being a nurse practitioner than diagnosing and treating conditions. You have to look at the big picture, assess for consequences, keep patients safe, and practice in an equitable, ethical manner. That means there will be times when you need to say no and enforce personal and professional boundaries with your patients.

We hope you found this post helpful and it gave you some new ways to address those boundaries with your patients while still showing compassion!

At SMNP Reviews, we support NPs at all levels of experience, from pre-certification through years of practice. Check out our additional resources to help you succeed!

And for even more (free!) resources for NP professional practice, check out these other posts on the SMNP Reviews blog:

4 Common Communication Challenges for New NPs
[Podcast] Non-Clinical Skills Every Nurse Practitioner Needs
[Podcast] Maintain Healthy Boundaries with Patients, Employers, and Preceptors