Boundaries in pediatric PDN/home health

Specialties Private Duty

Published

Scenario: young child has 16h/day x7days a week including school hours. A team of 4 nurses cover the shifts some full time others part time. Family is welcoming (including siblings) and have come to appreciate the assistance and care of skilled nursing. Two nurses are working on the day of child's birthday party. Party crosses between two shifts. Mom feels guilty that the other two nurses won't be there as they are scheduled off so casually invites them. ( more so because she doesn't want hurt feelings to impact her child's care as is a common fear of parents of medically complex children ). Child has been under agency care for several years. One nurse has been with the child since start of care. Newest nurse on case has been with child 3 months.

Clinical manager explains to nurses orienting to case that parent feels obliged to invite nurses to family celebration but traditionally and ethically all decline and only nurses scheduled to work attend.

Nurse A& B are working. Nurse A (the longest on case nurse ) brings a card. & token gift (something home made. & personalized, low out of pocket cost. Item is something child can use. & enjoys). Nurse B brings a card and token gift (say appropriate story book). Both nurses while present at party focus on attending to the child 'a skilled care needs , treatments, medications, etc. helping family & client enjoy celebration without being "obvious" ( as we know a good pediatric nurse knows how to be subtle/ in the background and still get the job done & ensure family has as typical of an experience as they desire. & is possible)

Nurse C is off as per usual schedule. Has been on case for a few years. Brings a card and token gift next shift worked as (s)he too has a fondness for child. & family. She politely declined the invitation as she does with all off -work requests from clients. Wishes the mom happiness & success in the birthday celebration. Mom understands.

Nurse D (newest nurse) decides to attend party. Brings one of her own children in same age range as the client & siblings. Brings a card & gift. (Gift is a little more expensive than the other nurses choices but not atypical for the types of gifts exchanged at children's parties in the community) Nurse D participates as a guest in the celebration along with their child. Doesn't offer or perform any skilled care but offers to hold/sit with child. Nurse D feels a "bond" with child/family as a mother with children in same age range as client/siblings.

Nurses working are a little uncomfortable with nurse D's off the clock presence/ participation in party.

Nurses who followed agency policy are uncomfortable but not enough to discuss situation with supervisors.

At next monthly supervisor visit parent makes an innocent comment to nurse manager about the party & who attended. She casually mentioned she was surprised nurse D not only attended but brought her child; ultimately she was glad client had a wonderful time & enjoyed the celebration, Parent is not upset.

Manager informally speaks with all 4 nurses to reinforce company policy. Notice reminder about gifts & professional boundaries policies is sent to all field staff.

I can understand feeling like you are friends with the parents/family as you work in closely in a home environment. But we are not. The client's school/home is our workplace. General policy is to wear scrubs and look professional, in addition to wear ID badges when not in home to reinforce the professional image.

What do you think ?

Would you attend a patient/family (invited) celebration on your off time?

What about gifts?

Do you buy gifts, items that are in excess of official agency policy?

What about intentionally introducing client/parents to your family? (Not referring to incidental meetings on days off in the community as ultimately this is bound to happen at the store, school, etc and saying this is my child/wife/husband etc)

Disclaimer....this is NOT about YOU. This is compilation of a few issues I've seen/ heard of occurring in the past few years working private duty pediatrics.

Specializes in Complex pedi to LTC/SA & now a manager.

I don't particularly care unless an off duty nurse is impeding my ability to care for my patient or if the actions of another adversely affect my job or relationship with the parents. (Not just nurse Sally came but you didn't so don't you like us?). Fortunately this is not an issue with my primary patient or family; or any of the other cases I regularly work with. Nurses have tried to get themselves in favor/friendly but some of the parents and the mom laughs and says "you know that you are getting paid to provide skilled care for my medically fragile child not hang out with me".

I am in awe of some of the gifts I've seen given from nurse to patient/family in the past year. Gifts I could not afford to purchase myself or family...certainly not but paying for a client or coworker.

Specializes in Peds/outpatient FP,derm,allergy/private duty.

I've seen it, too. I've made peace with the fact that I may lose a case if that is someone's expectation. I try to be the best nurse I can. I rarely if ever call off a shift (as some of the extravagant gift givers feel they have a right to do) and sometimes help on short notice when the client is genuinely in a bind or an unexpected crisis occurs. This has worked well for me so far.

Specializes in Complex pedi to LTC/SA & now a manager.

I have one case that is easy for me to get to on short notice but is generally staffed with regular nurses. I've filled in on VERY short notice for call outs or schedule adjustments (sometimes less than an hour notice). Mom is very appreciative and jokes that she's buying me a super hero cape for the holidays since I've come to the rescue quite a few times. (Mostly by coincidence that I happened to be off & in the area when help was needed. ).

Specializes in Pediatric Private Duty; Camp Nursing.

My families know that I sleep all day so I have a good excuse for not attending parties!

That said, I have gone to a high school graduation party and gave my ct a suitable gift. My husband and two girls were invited and attended, but my girls "telling tales" is a non issue in this case. This ct has some local fame for her outreach, always doing public events to promote fund raising, awareness, etc. She even spoke at my daughters' school and GS troops. (the agency approved it and I was off-duty- she had her HHA with her) She wants people to know all about her and her condition, so privacy is not a large concern to her. Of course she's a very different case than most others!

Specializes in OB, HH, ADMIN, IC, ED, QI.

It was great that all the nurses (except D) were "on the same page". It seems that no interface in regard to the party and agency guidelines occurred prior to the occasion. It would have been wiser for the Nurse Manager to communicate the boundaries expected of personnel, and invite discussion of same, before the event. Then all the nurses would be informed and crossing the boundary would have been unwise.

However that didn't happen, so Nurse D can't be chastised for her (unprofessional?) choice. I've been a Pediatric Case Manager, and no situation such as this came up. I'm glad that it did here, so that I had the advance opportunity to look at what my role would be if one occurred.

Specializes in Pediatric.
I personally see nothing wrong with attending the birthday party of a client, if the family wishes it.

I have a hard time understanding what boundary is being crossed.

I'm with you.

I don't know if my agency has a policy against giving gifts. The only thing I heard in orientation is we are not to receive them.

I think our agency has a dollar limit policy per year on giving AND receiving. Whatever. I've definitely gone over it. When I'm at the dollar store and I see something my client would need, I grab it. It hasn't caused trouble yet. I also grab stuff for the nurses the family can't provide- pens, Purell, clipboards. Whatever.

I've only been given a gift once. I didn't refuse it and the agency didn't find out.

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I disagree with arbitrary limits that are out of context of a situation. We went to a very expensive restaurant and took our nurse. The average entree price was $40. We paid for her entire meal. I can't fathom a situation, due to a gift price limit, where she should be expected to pay for her own meal at such an expensive place when she was FORCED to attend.

Specializes in Pediatric Private Duty; Camp Nursing.
I disagree with arbitrary limits that are out of context of a situation. We went to a very expensive restaurant and took our nurse. The average entree price was $40. We paid for her entire meal. I can't fathom a situation due to a gift price limit, where she should be expected to pay for her own meal at such an expensive place when she was FORCED to attend.[/quote']

My aforementioned college girl's family has a long-standing self-imposed rule that if you're on duty when they go out anywhere, they treat. Sadly I never got to go; she only needs HHA's in the daytime.

Specializes in Peds(PICU, NICU float), PDN, ICU.

At my agency the parent is expected to pay for us for outings. That doesn't mean they buy us a shirt we like just because we are at the mall. But it does cover tickets, admission, food at a restaurant, etc.

I have picked items up for patients if I've seen something they need that is fairly cheap. I do things as simple as bringing plastic grocery bags so the family has something to put trash in. I will occasionally accept food depending on the situation. The home must be clean and the person cooking must be clean. I prefer that its for a special event such as cake for a birthday. I had one family that shared recipes with me so much that we decided to make food at their home. I would bring in the ingredients for my dish and the parent would make their dish and we would share...of course my pt used the opportunity to work on OT skills! I've had parents give me pictures and really small gifts like a gift bag of pens for charting and a few pieces of candy. Not worth making a fuss or discussing it with my boss. But its the thought that counts. I've ordered pizza at work and shared a slice with a pt that asked me for a piece (orders allowed the pt to eat what he wanted).

I was in the hospital for gastroenteritis that lead to orthostatic hypotension due to severe dehydration. I couldn't eat without getting sick. I couldn't sit up without passing out. As I got stronger, I wanted sweet tea. Something about it seemed like it would settle my stomach. I'm not a heavy tea drinker. So in the middle of the night when I thought it might help, I asked my nurse for sweet tea. There wasn't any way to get tea in the middle of the night. The night nurse had some tea bags and sugar in her bag. She made the tea and it helped me. I'll never forget what she did for me. I'm sure somebody will find a way that she did wrong if they really want to. But I was eating and discharged about 24 hours later. I think big gifts are ridiculous and that no nurse should make their peers uncomfortable or to feel obligated. But a small gift can make all the difference in the world. I learned a lot from that nurse and no boss or government will ever change my mind about that!

Specializes in Pediatric.
I disagree with arbitrary limits that are out of context of a situation. We went to a very expensive restaurant and took our nurse. The average entree price was $40. We paid for her entire meal. I can't fathom a situation due to a gift price limit, where she should be expected to pay for her own meal at such an expensive place when she was FORCED to attend.[/quote']

Yes, exactly. When I was full time with one of my patients (only there one day a week) family outings were a sometimes daily affair. They've bought me many movie tickets, many meals.

Sent from my iPhone using allnurses.com

Yikes! I'm one of those nurses who regularly crosses boundaries. Some kids are just so much fun to spoil :) As the parent of a disabled child (does not receive nursing) I would be thrilled for more people to come to my child's party. The more the merrier, especially if they bring along a kid! I think it all comes down to what is best for that child/patient. But then, I am not a manager, just a rule breaker.

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