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Boundaries

Nurses Relations Article   posted

Boundaries in nursing could be defined as a therapeutic relationship putting the needs of the patient first. This relationship is considered the foundation of good practice. You can not create a lasting building without a good foundation. The same can be said about nursing practice.

Boundaries
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Patients are vulnerable. They are relying on nursing to give them care, encourage their independence, to increase or maintain their functional level. This takes a certain amount of trust. Trust is something that is multi-faceted. Trust in one's nursing practice is far different than trusting a nurse on an emotional level.

There is more than one nurse who gets entangled in some sort of proverbial web of emotionally needy patients, and/or manipulative family members. When dealing with long term illness without a chance of a positive outcome, it can put a patient on what could be considered a defense mechanism at the expense of the nurse. When multiple family dynamics are involved, even more so. Your goal is patient function.

Families can be crafty. Often will seek out the most emotionally immature nurse as if they have a sixth sense of such things. It helps them maintain some sort of control. The same could be said about the patient. Control issues come to light when a loved one, or one's self is critically or chronically ill. To recognize that control is an issue, be sure to have frank discussions with your patient about information. How do they want to communicate? Who in the family (if anyone) is to have what information. GET RELEASES SIGNED to reflect same.

They can see the nurse as access--perceived or not--to things that a patient or family feels they do not. There are some patient who have no desire for anyone in their family to know a thing. And that is OK, not for us to judge, and to follow.

Nurses who put their own needs to be valued before the medical needs of a patient's functional level are doing a dis-service to both themselves and the patient. And crossing a professional boundary. No matter what a nurse believes, or what a family or patient tells him or her, there are in fact other nurses who can care for the same patient.

In general, by putting our own egos in front of patient's best interests is non-therapeutic behavior. A nurse needs to use good judgement. Use their resources if they feel they are getting in over their heads. The patient's needs are first and foremost.

Do not enter into friendships/relationships with patients. A nurse can be pleasant, inquisitive, and engaged without becoming best buds. That is when a line is crossed, and a patient's expectation is for treatment may and most often can become beyond what a nurse can offer.

Be mindful and careful. It is unacceptable to "down" another caregiver for your own benefit. That is perceived as one being the "only nurse" who can care sufficiently for the patient. This is incorrect and demeaning. Everyone brings something to the table to help a patient to function.

There are other dimensions and practices that can assist. If a family is having a hard time accepting boundaries, get others involved. Create a plan of care with other disciplines that will benefit the patient.

We are not a team of one. Use what you can so that you are offering the best to the patient and family, but not to the point of allowing manipulation.

Finally, if you find yourself in a place where the best parts of your nursing practice are those which revolve around feeling needed and that you are indisposable beyond reason, that is something you need to seek support for outside of the walls of the facility. It is so important for your practice, your reputation, and your ethical standards.

jadelpn, LPN, EMT-B

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RNdynamic

Specializes in Critical Care, Float Pool Nursing.

I one time refused a patient assignment because the patient's family made a comment that they saw me in a stairwell going down to the cafeteria while they were going upstairs to the floor, and when they got upstairs thy thought their mom was not comfortable looking.

Their snide comment about seeing me in a location other than in their mom's room compelled me to tell them that I was going to find them a different nurse, because I felt that working with them was just not therapeutic for me.

Why not just reply that you were headed down to get something for lunch (or supper). I'm missing something here.

RNdynamic

Specializes in Critical Care, Float Pool Nursing.

Why not just reply that you were headed down to get something for lunch (or supper). I'm missing something here.

They were from China and expected caregivers to never leave the bedside of their elder family members, who they all but worship within their culture. This family was a problematic one who was dislodging the patient's OG tube by swabbing her mouth constantly and leaving the toothettes in her mouth next to her ETT, and laying an ipad next to her ear which was playing LOUD weird music on youtube. Meanwhile we were trying to sedate her with fentanyl because she was constantly being bothered while intubated.

Working with them and talking to them was just not therapeutic for me.

I had to examine this when working with a patient who was on the floor for a long time. Complex needs both emotional and psychological. Family was extremely controlling and manipulative. They had the entire hospital hopping to meet their demands and it was honestly ridiculous. I struggled nightly to firmly but tactfully balance between family demands and patient safety. Sometimes I left the shift knowing the patient was safe, but feeling very emotionally beaten down trying to also keep family happy in small ways that did not have anything to do with patient safety. Also the family used me as a sounding board a lot of times. I had to really examine my own boundaries and sought out education and advice from more experienced nurses.

One night I had to stick to my guns and refuse to give a PRN to the patient because it was not safe to do so. This judgement was backed up by docs who the family demanded that I call to bedside. I felt good about my decision but why did the family not respect my role more?

It's a shame that the family behaved like that because their behavior directly impacted the care of the child-- making nurses not want to work with that patient, and the ones who did were stressed out and had to be extra extra careful not to make a mistake because of distraction or feeling pressure or feeling judged.

ixchel

Specializes in critical care.

They were from China and expected caregivers to never leave the bedside of their elder family members, who they all but worship within their culture. This family was a problematic one who was dislodging the patient's OG tube by swabbing her mouth constantly and leaving the toothettes in her mouth next to her ETT, and laying an ipad next to her ear which was playing LOUD weird music on youtube. Meanwhile we were trying to sedate her with fentanyl because she was constantly being bothered while intubated.

Working with them and talking to them was just not therapeutic for me.

Your cultural awareness, sensitivity and acceptance is lovely. But hey, the nursing relationship is clearly all about you, so I guess it doesn't matter.

It is important to note that the professional relationship is intended to be therapeutic for the patient and/or family, not the nurse.

RNdynamic

Specializes in Critical Care, Float Pool Nursing.

I think it should be therapeutic for everyone.

I am a proponent of nurse-centered care over patient-centered care. Nurse-centered care utilizes a nurse's unique set of skills to maximize patient outcomes by integrating their individual preferences and goals to make them as productive and helpful to patients as possible.

Is that a new philosophy of nursing being taught now, nurse centered care?

Perhaps I am too old school after almost 4 decades of practice; I believe that the focus of our care is the patient, their needs, their health, their plan of care; not the nurses or other staff.

Perhaps someone could explain "nurse centered" care vs. "patient centered" care.

I think it should be therapeutic for everyone.

I am a proponent of nurse-centered care over patient-centered care. Nurse-centered care utilizes a nurse's unique set of skills to maximize patient outcomes by integrating their individual preferences and goals to make them as productive and helpful to patients as possible.

If you read the Nurse's Code of Ethics, which you should be incorporating in your nursing practice, you'll see that nursing care is centered on the patient and family, not on you, the nurse. There is no such thing as "nurse centered care." Your individual preferences and goals are irrelevant. Yes, a nurse has a special skill set, but it is used in conjunction with the patient's/family's preferences/needs. You don't get to autonomously practice on the patient/family your idea of what they need; you get to practice nursing within the limitations of the Nurse Practice Act for your state, the Standards of Care, facility policy and procedure, and the Nurse's Code of Ethics.

HappyWife77, BSN, RN

Specializes in Gerontology RN-BC and FNP MSN student.

As Nurses we need to "check" our selves at the door as we come in. It really isn't about us is it??

This is a great article that we all need reminded of. The more we choose to keep bondaries, the easier is it becomes. It is a natural response after a while....

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro.

I think it should be therapeutic for everyone.

I am a proponent of nurse-centered care over patient-centered care. Nurse-centered care utilizes a nurse's unique set of skills to maximize patient outcomes by integrating their individual preferences and goals to make them as productive and helpful to patients as possible.

Except often times our job DOES drain on us, no two ways about it. There are interactions that will be difficult for ANY nurse...but the pt still needs care. Sure it's nice when our interactions give us the warm fuzzies, but that can't be an expectation. Nor can it be an expectation that nobody likes ethnic music. The comment about theirs being weird is rude. Frankly I think it's weird to use the same 3 chords over and over and over and ooooover the way some American pop/rock does...but I digress.

That said, it would have been perfectly fine to say "Labor laws apply to RNs too," if they made a snide comment about you taking your lunch break.

It's also fine to require rather than request quiet, if the pt is overstimulated to the point of being unsafe. We do it with neuro pts all the time if they're having ICP issues. I have told families that they can sit quietly at the pt's bedside, but until the "pressure on their brain" is lower the pt can't be stimulated. The only time I've had an objection was a very nice gentleman who said for a while "But I thought you were supposed to talk to someone in a coma." He did seem a little slow and needed some reinforcement, but after a few explanations of what we needed him to do and why the pt needed him to do it, he stopped. It was just a matter of education about the reality of this particular situation as opposed to what he had thought.

Same thing with the swabs. If they had been explained why it was unsafe to leave dirty swabs in Mom's mouth, do you think they would have kept doing it? If they had been explained that repeated dislodging of the OG would necessitate repeated adjustment which was uncomfortable for Mom, do you think they would have been more careful? Especially after being shown and walked through how to safely swab her mouth?

ixchel

Specializes in critical care.

I think it should be therapeutic for everyone.

I am a proponent of nurse-centered care over patient-centered care. Nurse-centered care utilizes a nurse's unique set of skills to maximize patient outcomes by integrating their individual preferences and goals to make them as productive and helpful to patients as possible.

Are you just kidding right now? I'm being serious when I ask that. Or maybe you're from a different cultural background?

I belong to the school of thought that it's all about the patients. However I do think that some more difficult or needy patients/families need to have that boundary defined for them so everyone knows the exact role of the nurse-patient relationship and no one crosses that line.

As far as nursing being therapeutic-- my job satisfaction does play into that and I wonder if the poster who said that meant that it should be a satisfying job (most days of course!) and if it's not, things should be examined further.

As for myself, I am becoming a firm believer in mental health services for *all* people who work in the caring-type jobs such as nurses, firefighters, police officers, social workers and such. Seeking those services and learning ways to cope and take care of ourselves after seeing what we see at work will make us better people to live with to our family/friends and also help us to do a better job with our patients and their families.

Thanks for the article. Yes, I think newer nurses are more prone to cross boundaries. I'm sure I have in minor ways over the course of my career. Younger nurses are more vulnerable to being manipulated by patients and families out of a need for approval.

It's important for us all to learn from our missteps.

As far as the nurse who fired herself from the Chinese family, sometimes it is important to rotate difficult families. But, part of being a professional is to learn to handle these situations in a detached manner and not to expect any therapeutic gratification from our patients and their families. We are there to serve them, not visa versa.

We are paid a good living to do so. Sometimes that entails explaining boundaries and documenting their actions and behaviors in order to protect ourselves legally. We are also obligated to informed those higher in the chain of command as to these problematic situations and document that as well.

Then we go home to our own lives to refuel emotionally.

There are some units that will make assignment based on a nurse's strengths. That could be a type of "nurse centered" care. There are some nurses who are good with certain populations. There are even more nurses who can deal with difficult families without so much as a bat of the eye.

So "nurse centered care" could mean a reflection of strength, and assigning nurses based on strengths.

(and all "kidding" aside, I will turn, repo peri care 2 of your patients for you to get the sputum culture for mine.....playing to strengths....)

There are some units that will make assignment based on a nurse's strengths. That could be a type of "nurse centered" care. There are some nurses who are good with certain populations. There are even more nurses who can deal with difficult families without so much as a bat of the eye.

So "nurse centered care" could mean a reflection of strength, and assigning nurses based on strengths.

(and all "kidding" aside, I will turn, repo peri care 2 of your patients for you to get the sputum culture for mine.....playing to strengths....)

I appreciate your response and definition of "nurse centered care".

I don't agree that what you offered is nurse centered. I feel that what you described was still "patient centered" as the decisions were made relative to the needs of the patient, not the needs of the nurse. Seeking out the most proficient nurse in a particular skill is still centering the care around the needs of the patient, it is simply utilizing all assets/tools available to do so, in my view.

I belong to the school of thought that it's all about the patients. However I do think that some more difficult or needy patients/families need to have that boundary defined for them so everyone knows the exact role of the nurse-patient relationship and no one crosses that line.

As far as nursing being therapeutic-- my job satisfaction does play into that and I wonder if the poster who said that meant that it should be a satisfying job (most days of course!) and if it's not, things should be examined further.

As for myself, I am becoming a firm believer in mental health services for *all* people who work in the caring-type jobs such as nurses, firefighters, police officers, social workers and such. Seeking those services and learning ways to cope and take care of ourselves after seeing what we see at work will make us better people to live with to our family/friends and also help us to do a better job with our patients and their families.

Like this very much because I think it brings the discussion back to what the OP was hitting upon with boundaries. Boundaries are necessary because there is an "I" involved-as in the nurse is a person in his/her own right, not just a source of care. The patient must be the focus, but keeping the boundaries clear (and taking care of issues on our end- as anon456 suggests) is beneficial to both parties.

cinlou, BSN, MSN, RN

Specializes in Emergency and Critical Care.

I think it should be therapeutic for everyone.

I am a proponent of nurse-centered care over patient-centered care. Nurse-centered care utilizes a nurse's unique set of skills to maximize patient outcomes by integrating their individual preferences and goals to make them as productive and helpful to patients as possible.

As an educator, I must say I have never heard of "Nurse-centered care", I would Love to have your reference to that so I can read a bit more about this new narcissistic approach to caring for the patient. I am wondering if in your 3 years as a BSN, RN your role models in school had this same thought process, or if somehow it was mis-understood as to the role of a nurse. Knowledge does not make the nurse the center of the universe, it provides the nurse the skill and knowledge to make the patient the center of care. I guess all the research that has been done and all the classes that we provide in cultural sensitivity and awareness were not part of your education, so very sad. Learning about other cultures to me is very interesting. Perhaps this family needed some quality education, so that they could help assist in the care of their family member whom they see as a very important part of their life.

Sometimes there is a personality conflict with patients and family that may require a nurse to change assignments so that the patient is receiving the best care from their care giver. Sometimes taking care of these patients can be very draining on the care provider. But changing assignments is not always possible, so finding a middle ground is important to all the parties involved. Educating the family can go a long way.

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