Advice on "setting boundaries"

  1. Hi! I recently passed the NCLEX, got my license, and will start my very first job in a couple of weeks. Aside from all the other new grad concerns (time management, etc.), I know that I will have a HUGE problem setting boundaries with difficult patients and their families. During clinicals, I even had a patient tell me, after spending pretty much the whole day harassing and insulting me, that nobody was ever going to take me seriously if I didn't quit being so nice. My response: "Well, I'm not going to be rude to you."

    Anyway, I am asking for advice because I think it would be very helpful for me to already have a couple responses ready, especially at first, so I can be more confident, and don't end up getting walked on...or completely blowing up at people. I've spent a lot of time in food service, and had a pretty hard time dealing with rude people. And by hard time, I don't mean being a push over, I mean getting a really bad attitude, and occasionally exploding (luckily for me, it was almost impossible to get fired from that place). I knew this sort of behavior would be unacceptable in clinicals, and because, apparently, I have no idea how to be both firm and polite, I ended up on the opposite end of the spectrum.

    SO...what do you say to people who are giving you problems? I know there will be a lot of grin-and-bear it type stuff going on, that's not what I have issues with. It's things like patients who aren't being compliant, ripping off their O2 masks, patients and families yelling. Also, for example, one of my patients (who was super sweet...and homeless) had his girlfriend (also homeless) staying with him, which is not a problem. The problem was, she was acting like she was staying in a hotel, and kept demanding that I bring her ice cream, sodas, socks, toothpaste, crackers, anything extra she could think of. If I would tell her it was for the patients or something like that, she would get so rude and combative with me, interfering with what I was trying to do for my patient, that I decided it wasn't worth the trouble, and I would just do whatever it was. Which is when a nurse told me to grow a spine, and that I'm creating more work for other people on later shifts because now, she expects that sort of treatment. I really don't want to put my coworkers in that position (and also I want them to like me!).

    I'd love to grow a spine, I'm working on it. I don't have a huge aversion to conflict, I just don't know what to say! A lot of people chose to ignore ridiculous requests, or just keep acting like they "forgot," but I would rather address an issue, if possible. Also, another problem I seem to have, is I don't know what behaviors from a patient are considered crossing the line, and what behaviors I should accept from my patients and their families. I know that I will get better with practice, but I would really appreciate any sort of advice that could help me learn how to be firm and maintain my dignity when necessary, while staying polite and professional.

    Thanks, y'all!
  2. Visit SubSippi profile page

    About SubSippi

    Joined: Mar '12; Posts: 937; Likes: 3,348
    from US
    Specialty: 2 year(s) of experience


  3. by   loriangel14
    As for unreasonable requests I just smile and say " No, sorry, I can't do that" and walk away.If they are rude I say " that's not acceptable and I will come back when you are ready to ready to be polite". It takes practice.
  4. by   SaoirseRN
    Sometimes what works for people who are speaking rudely, insulting you, or otherwise speaking to you in a way that is making you feel uncomfortable is to call them on it.

    "I don't like the way you are speaking to me. I am here to help you, but I can't tolerate this behaviour. I will come back in 15 minutes, and we can try this again."

    And then come back when you said you will be back, and literally start over. "It's time for your dressing change" or "Now, what can I help you with?" If they've stopped doing what you asked them to stop, then carry on!

    It won't work for everyone, and when it does work you won't usually get an apology, but often they'll realize they need to keep their insults to themselves while you are in the room. Walking away, (more than once if need be) shows that you aren't going to tolerate their abuse. Coming back when you say you will shows you will give them a chance to behave like respectful adults.

    Patients have need of nurses, but I'm not a handmaiden and I'm not a servant. I will always help, as long as you show me basic respect. They don't need to love me or sing my praises. They can be as grumpy or gruff as they like as long as it isn't directed at me or my coworkers. I might even make it my mission to make them smile -- just don't call me names or shout in my face, and we will get along just fine.
  5. by   SubSippi
    So you don't get in trouble for walking out of the room?
  6. by   loriangel14
    Nope.We are nurses and we are not there to be verbally abused.You have to draw a line.
  7. by   SubSippi
    Ok. Sorry if I'm sounding thick-headed, I just want to know what y'all think this sounds like. So if someone is being combative, and I said something like, "I know you're upset, but I can't tolerate this behavior. I'm going to let you cool down, and I'll be back in a few minutes," and then came back a little later acting like nothing happened, that would be ok, right? Or is that something that could get me in trouble?

    Ha, if you can't tell, I'm very concerned about preparing myself for conflict!
  8. by   meanmaryjean
    I think the BEST approach is to run these scenarios and responses past your new manager- and say "What is acceptable on this unit? How would you like me to respond when these types of situations arise?"

    You did an excellent job of presenting your issue in writing, analytically and with good self-awareness - do the same verbally to your manager. If you respond in a manner he/she has already said is OK- you will always be backed up.
  9. by   loriangel14
    Quote from SubSippi
    Ok. Sorry if I'm sounding thick-headed, I just want to know what y'all think this sounds like. So if someone is being combative, and I said something like, "I know you're upset, but I can't tolerate this behavior. I'm going to let you cool down, and I'll be back in a few minutes," and then came back a little later acting like nothing happened, that would be ok, right? Or is that something that could get me in trouble?

    Ha, if you can't tell, I'm very concerned about preparing myself for conflict!
    Physical violence is some thing different.Then you need to get someone else involved and don't forget to document, document,document in all cases of inappropriate behaviour.
  10. by   SubSippi
    Thanks, that is really good advice! Especially about talking to a manager before anything happens, I think that will do a lot to alleviate my worries.
  11. by   SaoirseRN
    Quote from SubSippi
    So you don't get in trouble for walking out of the room?
    Of course if something emergent was happening you can't just leave, but no, I don't. I am not refusing care. What I am doing is refusing to be abused and giving the patient an opportunity to start over. I will go back, I will provide care, but I won't tolerate abuse.
  12. by   SNB1014
    I had this issue the other day with the adult daughter of my elderly stroke pt. She was so passive aggressive , annoying, rude and over bearing.
    She wanted me to call a code stroke overhead when he mother couldn't get a burp out after lunch. I fixed the burp situation, if u will, but she criticized me and oh so helpfully web MD educated me every moment I was in there. I am putting both shifts mildly cuz I feel a stroke coming on myself just thinking about it.
    So im from Nj but now work in tx. What I would say if I was back home would not fly. Some of these old southern belles dont like the taste of their own dish when i serve it back to them, if u will.
    Also passive aggressive ppl are my nemesis. I consider myself assertive most of the time.
    Master the art of answering annoying people as you are heading and walking out the door and then proceed to close it for " privacy". Don't be mean. Gets you nowhere.
    Don't ever say you had something along the lines of more important/ priority. She came right back at me and said " oh that's odd I didn't hear them call a code blue in this hall" GRRRR WTH. lol
    I say something along the lines of " oh wow sorry that took a bit I just had 3 fires In a row I just put out! Ha-ha, how can I help you now?"
    If that doesn't work and they are belittling me or rude, I call em out.
    " the way you're speaking to me is unacceptable . It may look like I'm wearing pajamas to work, but I am your registered nurse and expect to be treated and spoken to like the well educated professional that I am, with the same respect I give you. so that said ,would u like to try saying that again?"

    They are usually flustered and realize I won't be taken for a fool. If the problem doesn't resolve, tell your charge and or manager, document!!!! And request a different assignment next shift. My director said it is professional to acknowledge and accept when their is simply no therapeutic nurse pt relationship and the care if suffering, either that patient or your others. Some pts are rough but respond better to someone else. Sometimes it really isn't you it's them.

    I hate to say it , but I handle my patients the way I envision dealing with my future children. I am firm but funny, always thinking of their safety and my time, tell them why matter of factly when they ask and always throw a splash of guilt and fear in the mix if my not so subtle joke failed to send my message.

    Example ) post cabg pt refuses / ' forgets" to practice his incentive spirometer.
    "Sir! No one told me what a rebellious soul u are. Why have I not seen you practice your breathing? I know it hurts but we can work through the pain easier than don't really want me to have to tell your surgeon you haven't been following his treatment plan, right? * insert comical pouty face and then quick smile and put it in their hands*
    Bottom line is that humans are blessed and flawed by being autonomous . if they aren't following the plan let the DR know to see if there is an alternative instead but it isn't your job to keep someone's bipap on for 12 he's straight. You have stuff to do for people who enjoy getting well :-)
    Kill em with kidness then walk away baby.
    Last edit by SNB1014 on Jul 4, '13 : Reason: spelling
  13. by   SNB1014
    and oops i earlier typed out this whole answer but answered to a different topic whoops!
  14. by   SNB1014
    Quote from SubSippi
    Ok. So if someone is being combative,
    annoying? urg okay. needy? hey aren't we all? combative, though? not cool, wont be tolerated.

    firstly, since you seem concerned, let me say that the majority of my days do not include having to set these boundaries, etc. i dont look for conflict. it also helps to laugh about it with your coworkers/complain to your husband at night lol

    butttt that said, COMBATIVE is different. someone who is having dementia and "attempting" to kick me i wont call a "code grey" (aka secuirty) to the room. i will call another person into the room and usually the confused will be temp. distracted by the new face, new voice, new smiles and stop.
    if not, i stay with another staff member in the room while i call the dr for a stat 1x dose or stat/prn IM/IV antipsychotic/sedative, etc. and have them stay in a Geri-chair at the nurses station.

    if a family member (aka not the patient and someone i have no actual patient responsibility to) starts doing this, my charge, my fellow nurses and the security team will be called. its a cold day in Texas when i tolerate that nonsense.

    if you reallllllllly want to be informed, look into your policy handbook. some facilities, believe it or not, do not allow their staff to press criminal charges on a patient or visitor.

    mine thankfully does, and God forbid that i am ever physically threatened or serious verbal abuse, i will call 911 right after i call security. our security guys are off duty cops. we also take a class in "defensive maneuvers" and non violent crisis intervention
    you will find a lot of cops, fire and ems workers have a kinship towards nurses.

    nurses, you are professionals and at your place of employment. no different than when my husband wears his suit to the office. if his client did that, they would be "escorted" out in a heartbeat and no one would feel guilty.