Codependant or just Caring? Nursing ED patients

JeanettePNP, MSN, RN, NP · Feb 19, 2006

I'm not a nurse but I would like to become one, and the nurses you describe sound like model nurses whose example I would want to follow. The caring and warmth shown by these nurses will stay with these girls for a long time. Quite possibly it's the first experience of their life being totally cared for and accepted. I'm not getting why you think it's wrong. Maybe the more experienced nurses can help me understand.

dachweiler · Feb 19, 2006

It goes against the way I was trained too. I'm a nurse & "Behavioral Health Rehabilitation Specialist" with 17 years psych experience.

I know it can appear they are "model nurses" but they are not! I have seen this frequently by my fellow coworkers/nurses and it does the patients harm in the long run.

There are professional boundaries for good reason. You can be very warm and caring without crossing the line.

The recovery process belongs to the patient. While occasional appropriate self-disclosure can help the patient to open up or motivate the patient by providing a role model, too much self-disclosure removes the focus from the patient's own recovery. Too much "babying" can create a very dysfunctional dynamic. These patients need to learn coping skills.

The bad feelings should be dealt with by an experienced psychologist/licensed counselor.

Nurses are not counselors or therapists unless they have acquired a higher degree/licensure. Nurses cannot and should not assess, test, diagnose, treat, or advise on problems beyond the level of their competence as determined by their education, training and experience.

Bagwash, you are right to be concerned.

Thunderwolf, MSN, RN · Feb 19, 2006

I much second the thoughts of dachweiler.

I could not have stated it better.

bagwash · Feb 21, 2006

Thanks everyone for your replies. Glad to get a bit of feedback as at the moment I feel pretty outnumbered by nurses of this "over-helpful" type. The manager is dead against this type of behaviour but she is fairly new (though very experienced) and she is largely hated, especially by the nurses in question, so they generally ignore her and just do what they've always done.

ChayaN--the problem with this type of "care" has already been summed uo well by dachweiler and Thunderwolf. But just to add a few points--it becomes questionable whose needs are really being looked after--the patient's or the nurse's? Nurses like these "need to be needed" and become almost addicted to the "warm fuzzy" feeling of making the patient feel special and, worse still, having the patient think of them as special. Consequently all the nurses who don't coddle them start to seem mean and uncaring. What happens when the "special" nurse is not around? The patient doesn't trust the other "mean" nurses. This is hardly therapeutic.

It is called "splitting" because it encourages the patient to split the team into "good" and "bad" carers. Another probllem is that the hospital becomes this totally unreal place where the pt gets rewarded for regressed behaviour. This makes it impossible or at least very difficult for these pts to live in the real world. Little wonder they keep returning to the hospital. This is NOT in the patient's best interests!

Thunderwolf, MSN, RN · Feb 21, 2006

Bagwash...well said.

KatieBell · Feb 21, 2006

Thanks everyone for your replies. Glad to get a bit of feedback as at the moment I feel pretty outnumbered by nurses of this "over-helpful" type. The manager is dead against this type of behaviour but she is fairly new (though very experienced) and she is largely hated, especially by the nurses in question, so they generally ignore her and just do what they've always done.
ChayaN--the problem with this type of "care" has already been summed uo well by dachweiler and Thunderwolf. But just to add a few points--it becomes questionable whose needs are really being looked after--the patient's or the nurse's? Nurses like these "need to be needed" and become almost addicted to the "warm fuzzy" feeling of making the patient feel special and, worse still, having the patient think of them as special. Consequently all the nurses who don't coddle them start to seem mean and uncaring. What happens when the "special" nurse is not around? The patient doesn't trust the other "mean" nurses. This is hardly therapeutic.
It is called "splitting" because it encourages the patient to split the team into "good" and "bad" carers. Another probllem is that the hospital becomes this totally unreal place where the pt gets rewarded for regressed behaviour. This makes it impossible or at least very difficult for these pts to live in the real world. Little wonder they keep returning to the hospital. This is NOT in the patient's best interests!

I do not work with patients with Eating disorders, clicked on this because I thoguht it was Emergency Department (ha!) but I would like to add for CHaya that these behaviors are VERY unhealthy for both the patients and nurses.

The idea of hospitalization is to allow patients to develop life/coping skills and relationship skills that will allow them to function in appropriate ways in the "real world". Most of these patients need to learn to accept them selves and love themselves, rather than have someone accept and love them. In addition, it is completely possible to accept and be warm and caring with your patients without crossing the line of giving gifts, notes, etc. In addition, they need to learn how to function in a world that does not always give gifts and hold hands. They need to learn not to crumple or fall back on poor skills when life "lifes" on them. They need to do it themselves, not have a nurse do it for them. Nurses can be great cheerleaders, allowing for the patient to reflect back successful behaviors and encourage them, but patients need to learn to cultivate support for themselves.

Once notes, gifts and extreme personal attention start what is actually occurring is that the NURSE is meeting the nurse's need to feel important, and cared for and such, which is not what the patient is in the hospital for.

One thing my school emphasized again and again is that even as students, we needed a life outside of nursing. We were told to meet our emotional needs outside of the "job". Because of this, I expanded my interest in my pet dog and now he has earned several obedience titles, and we are working on agility training. I have made so many great friends through my work with the dogs, that it has really expanded my social circle of friends. I do not have a family (yet! maybe soon!) so I do not have that focus. But I have seen this odd dependent behavior in many nurses, and usually when I talk to them they have nothing outside of the hospital to really carry them over- no church involvement, no family life, no hobby like gardening, or hiking that they really enjoy, so they are getting all their emotional needs met at work.

As a Nurse, work can be quite stressful and one can become very involved and attached to a patient- especially I imagine in Psych. However, we must meet our own emotional needs elsewhere, and concentrate on meeting the needs of the patients treatment plan at work. I'm a little surprised that this may not be emphasized everywhere....?? :mad:

rn/writer, RN · Feb 21, 2006

I was a psych nurse for a long time, and let me tell you, the behavior you have described has crossed a critical line.

A therapeutic relationship is, by very definition, unequal. The practitioner is supposed to set and keep boundaries that help the patient to focus on self-discovery and self-care. Staff should not be coming to the unit looking for affirmation and ways to feel good about themselves. Anyone who doesn't feel secure enough to resist this urge, should probably work another unit until they are in better shape.

It's bad enough that co-dependent behavior distracts the patient from their primary purpose, but what's even worse is that it can actually make patients worse! Many patients come to the psych ward through damage done by people with poor or non-existent boundaries. Some have a very fragile sense of self and will try to merge with a stronger personality in the hope of finding a safe place to take refuge. A nurse who offers this false--and necessarily temporary--solution is making betrayal inevitable.

Other patients have learned to manipulate, and staff members who let themselves get sucked into responding for the sake of getting personal strokes had better take a long, hard look at their own level of neediness. If they don't, they are liable to end up making all kinds of illicit and implicit bargains and compromises that violate every level of ethical care.

This doesn't just harm the obvious patient. It also undermines the success of the other patients on the unit who can almost always sense favoritism and can easily develop jealousy and resentment. Not to mention a lack of trust for the offending staffer.

Ultimately, any clinical relationship that ends up being as much (or more) about the practitioner as it is about the patient is unhealthy and inappropriate. There should be safeguards on psych units that help staff members keep themselves and each other honest and catch the early signs of improper bonding. This should be done without judgment, but with the clear understanding that we owe it to ourselves, each other, and, most of all, the patients, to demonstrate the good kind of limits that protect and promote trust and healing.

If we don't model this kind of respect for these damaged patients, who will?

Thunderwolf, MSN, RN · Feb 21, 2006

Excellent posts, everyone.

bagwash · Feb 22, 2006

Great to read the last few posts.

The sad thing about these nurses is that they are kind, caring but insightless people who have absolutely no idea how harmful their behaviour is. And as I read in another thread somewhere around here, lots of hospitals capitalise on co-dependant nurses (they never say no to unpaid overtime!) thus entrenching all kinds of unhealthy behaviour.

In this particular ward the co-dependant nurses are enraged that anyone would dare question their approach and are as determined to cling to their behaviour as the patients are to cling to their condition. (One thing I have noticed is that the patients who are really motivated are generally not attracted to this kind of "care" and don't bond with these nurses.)

I think it all goes to show how important ongoing training and supervision of mental health staff is. Unfortunately there is practically none of either in this facility! I feel sorry for the manager who is subverted at every turn. It makes the unit a very divided and dysfuctional environment--and doesn't that bring out the worst in patients with personality disorders (which many of our ED's seem to have)!

JeanettePNP, MSN, RN, NP · Feb 22, 2006

Thanks for the explanations; it makes a lot of sense now that you've explained it (and hopefully I won't make the same mistakes if I ever become a psych nurse.) I feel so silly now. :sofahider

I guess I was thinking about the other extreme - nurses who do not treat patients respectfully, humiliate them and make them feel less than human because they're in the psych ward.

bagwash · Feb 22, 2006

Thanks for the explanations; it makes a lot of sense now that you've explained it (and hopefully I won't make the same mistakes if I ever become a psych nurse.) I feel so silly now. :sofahider
I guess I was thinking about the other extreme - nurses who do not treat patients respectfully, humiliate them and make them feel less than human because they're in the psych ward.

No need to hide behind the couch ChayaN

Its good to be able to say what you think and hear other points of view and even change your mind-- or not, depending.

Hope you enjoy your nursing studies