Advice on "setting boundaries"

[SubSippi]

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!

[SNB1014, RN]

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.

[Morainey, BSN, RN]

Being calm and assertive is something I still struggle with, but it's a 'fake it til you make it' skill. My helpful hints are don't blather on and don't apologize if the request is unreasonable.

Scenario: A 15 year old patient's mom is staying with him the night. She asks for applesauce, apple juice, orange juice, toast, and if we have any sandwiches, that would be GREAT. No please, thank you, or alternatives sought (ie, "are there any vending machines or places open in town where I could get XY and Z?")

Old me: "Ummm... sure. Let me just get those for you." *goes, gets the stuff, complains about them at the nurses' station*

New, calm, more assertive me: "We don't, unfortunately. There is a vending machine on the ground floor". *leaves*

Fight the urge to apologize or blather away excuses. The more you do it, the easier it gets.

BY THE WAY this doesn't apply to reasonable requests of the actual patient.

[MrChicagoRN, RN]

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.

Good advice.

And seeking the counsel of other reasonable clinicians is never a bad idea.

to OP:

It's OK to say no, but a brief explanation and offering an alternative is a great way to handle it. And by brief, I mean ~15 words or less. "No, I'm sorry I can't do _______, because_______, but perhaps (you/I/visitor/the doctor) could _________"

Somebody is mildy rude, ignore it. They're sick, scared, angry, under a lot of stress, whatever. They're reacting to what's going on, and it has nothing to do with you.

Very rude? I just say, I'll try to help you to resolve this issue, but I would never speak to you that way, and would appreciate it if you would do the same.

Continuing rude? You're upset right now, I'll come back when you are feeling calmer

Keep in mind that acting out may also be due, in part, to pain or anxiety, so an offer of medication may be appropriate.