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.
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.
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....)
Specializes in NICU, PICU, Transport, L&D, Hospice.
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.
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.
ixchel
4,547 Posts
Are you just kidding right now? I'm being serious when I ask that. Or maybe you're from a different cultural background?