PDN and boundaries

[quickkarma]

I am curious of others opinions on private duty nursing and the extensive boundary crossing that is seen in this type of setting. I've seen it all, gifts, vacationing together, planned lunches, visiting while on maternity leave. Both sides-family and nurse. Sometimes nurse is on duty, sometimes not. Just bizarre. I do understand the need to share phone numbers because communication is more accurate without a middle-man. But Ive heard of nurses bringing in loads of baby gifts after a minor disagreement between client's family and nurse. Yikes. I just try to follow the rules, but some of these families seem offended that I'm simply cordial and don't become their close friend. And then it becomes awkward. I'm not in this job to expand my friend list! The latest family, which I thought were the most "normal" yet, have insisted it's impossible to not be close with the nurse. I just don't agree.

I am, however, hoping and planning on switching out of this type of nursing soon. At any rate, looking for thoughts and opinions here. Am I too conservative? Is this as common as it appears to be?? Thanks...

[Kitiger, RN]

Many families are more comfortable having a "friend" in their house instead of an employee, but you do need to take care of your boundaries.

I had one mother unexpectedly, out of the blue, buy me an expensive Christmas gift. She and I were not that close, although we got along OK. I couldn't have accepted that gift even if we were close! When I told her that is was against policy, and that I could not accept it, she became angry! She had shopped specifically for me, buying something that she knew that I would like. (It was a great gift!)

It was a mess.

Since then, wen I first start, I have told my clients that gifts are against company police, and for good reason. I am paid for my services, and they don't owe me a thing.

Another thing they don't owe me is enough hours. That is my scheduler's responsibility. The family does not have to arrange for me to replace the hours that I lost when - for example - their child was in the hospital.

They know, too, that I will refuse to share in their food. If they have popcorn, sure it smells good, but they don't have to give me any. The same goes for dessert. Now, if I'm there during a birthday party for my client, I may accept a piece of cake, but that's about it.

I do sometimes bring in items that make my job easier, like medicine bottle caps that accept a syringe. (And they only cost about 30 cents each.)

[doodlebuttRN]

It's very common, and I believe sometimes the process occurs over months and years in some cases, the nurse not quite realizing how it occurred.

When you look at it from parent's perspective, there is an underlying anxiety fueled by fear their child will not get the care he or she needs. They've probably had some nurses who gave good reason for their fear.

When they find a good nurse, they naturally want to cling to the nurse and find various ways of flattering and encouraging an emotional investment, including the offering of "perks" such as offering to sign off timesheets for hours the nurse was not on the premises, gifts,etc.

I don't think it's a healthy situation for nurse or family, but it's often the path of least resistance, and one I would actively resist. Over a period of years I've seen most such intertwining end very badly.

Yes, Nurse 156, this is absolutely correct (as usual). I will tell you from my own experience... I cared for a child for many years and recently left the case because the family 'turned' on me (for lack of a better descriptor) Of course, I realize now that in my ignorance I failed to maintain appropriate boundaries with these parents. I was in their home 40-50 hours a week, for years, taking care of the most precious thing in their lives.. Their child. There is a deep level of trust that develops during that time.

HOWEVER.... Despite having been an RN for almost 10 years before ever working in the home (worked in hospital and LTC and LTACH, but never PDN, and never peds) I really didn't know what I was getting into. I thought, 'these people are so nice, they appreciate me, etc.' and they really did, at first. They validated something in me that needed validation as a nurse and as a person. I never did anything unethical, as some of the stories on AN, I just opened my heart up to a family I was working closely with for a long time.

I have read on AN all about PDN nurse/parent problems, and I truly didn't think it would happen to me... Until it did. I've learned my lesson, and though it's difficult to admit, as a professional, but I'm actually in counseling to deal with the feelings I'm left with. I hope y'all won't judge me too harshly. Believe me, I'm judging myself.

So here's the moral of my story, learned at a high price... It is easy to cross that line of your professional boundaries, but it is damn near impossible to 'un-cross' it afterwards. I had he very best of intentions, and went into this job as a professional. I found myself caught up in family issues and in family's eventual preference for nurses who would follow their demands without regard for orders, my job, or my license.

When I finally left, I felt nothing but overwhelming relief. And that tells me all I need to know...

[JustBeachyNurse, LPN]

Yes, Nurse 156, this is absolutely correct (as usual). I will tell you from my own experience... I cared for a child for many years and recently left the case because the family 'turned' on me (for lack of a better descriptor) Of course, I realize now that in my ignorance I failed to maintain appropriate boundaries with these parents. I was in their home 40-50 hours a week, for years, taking care of the most precious thing in their lives.. Their child. There is a deep level of trust that develops during that time.

HOWEVER.... Despite having been an RN for almost 10 years before ever working in the home (worked in hospital and LTC and LTACH, but never PDN, and never peds) I really didn't know what I was getting into. I thought, 'these people are so nice, they appreciate me, etc.' and they really did, at first. They validated something in me that needed validation as a nurse and as a person. I never did anything unethical, as some of the stories on AN, I just opened my heart up to a family I was working closely with for a long time.

I have read on AN all about PDN nurse/parent problems, and I truly didn't think it would happen to me... Until it did. I've learned my lesson, and though it's difficult to admit, as a professional, but I'm actually in counseling to deal with the feelings I'm left with. I hope y'all won't judge me too harshly. Believe me, I'm judging myself.

So here's the moral of my story, learned at a high price... It is easy to cross that line of your professional boundaries, but it is damn near impossible to 'un-cross' it afterwards. I had he very best of intentions, and went into this job as a professional. I found myself caught up in family issues and in family's eventual preference for nurses who would follow their demands without regard for orders, my job, or my license.

When I finally left, I felt nothing but overwhelming relief. And that tells me all I need to know...

At least you learned before it got worse and your license was at risk

I find it worse when other nurses decide they need to be BFF with the parent and gossip about their colleagues. I won't play that game. I will advise the office if I witness the behavior first hand or if the parent tries to bait me into asking/discussing other nurses. Such as "oh your working tonight because nurse X did a VERY BAD THING and the office has to talk to her".

Me "I'm sure if the situation is a concern for others we will get a blast notice. Are there any concerns for tonight?"

"It was VERY VERY BAD"

"Did you bring your concerns to (manager) I can have on call get her to phone you if you like to discuss"

"Oh she knows. It was VERY BAD"

"Ok if no concerns I will get things set up now." And started to attend to the kiddo.

She started the next day with unfounded complaints about me including that I wouldn't take her concerns about a colleague (already reposted by her) seriously enough.

Another colleague tried to get me to help her sabotage the other long term nurse on a case. I wouldn't play that game. Ultimately she pushed me out instead (without the other nurse's help). This colleague sought family favor and would buy gifts all the time. Told the mother that I wouldn't let her in on her day off (I was bathing the client at the time) to bring in gifts. The mom backed me. Karma hurts. Though I'm not at that agency anymore. A nurse from a 3rd agency witnessed some of this "colleague's" shenanigans at school and overheard her talk about me. I think this nurse may have even complained to the school about unprofessionalism. Ultimately in an unprecedented move the agency management actually brought a replacement nurse to school and pulled this nurse from the case mid shift, parent was aware and consented. I do not know what egregious act finally did this nurse in but it's quite possible the school administration complained about professionalism. I heard it included crossing boundaries.

[Adele_Michal7, ASN, RN]

I have thought about buying one of my patients some Artificial Tears and Culturelle(both are an ordered treatment for the client) because the caregivers either refuse to buy it or cannot afford it.

The child really,really needs them.

I know Medicaid does not pay for meds that are OTC even if ordered by the physician.

That's sad, and IMO abuse that's reportable to state agency.

[JustBeachyNurse, LPN]

I have thought about buying one of my patients some Artificial Tears and Culturelle(both are an ordered treatment for the client) because the caregivers either refuse to buy it or cannot afford it.

The child really,really needs them.

I know Medicaid does not pay for meds that are OTC even if ordered by the physician.

You need to notify the agency. NJ Medicaid will cover these items with an Rx and there are Rx brands that can be substituted. This would cross the line and create parental dependence on you. It can even be considered an ethical violation by the BoN. If the parent refuses to purchase it's medical neglect. If the parent cannot afford there are other sources to cover.

[JustBeachyNurse, LPN]

Many families are more comfortable having a "friend" in their house instead of an employee, but you do need to take care of your boundaries.

I had one mother unexpectedly, out of the blue, buy me an expensive Christmas gift. She and I were not that close, although we got along OK. I couldn't have accepted that gift even if we were close! When I told her that is was against policy, and that I could not accept it, she became angry! She had shopped specifically for me, buying something that she knew that I would like. (It was a great gift!)

It was a mess.

Since then, wen I first start, I have told my clients that gifts are against company police, and for good reason. I am paid for my services, and they don't owe me a thing.

Another thing they don't owe me is enough hours. That is my scheduler's responsibility. The family does not have to arrange for me to replace the hours that I lost when - for example - their child was in the hospital.

They know, too, that I will refuse to share in their food. If they have popcorn, sure it smells good, but they don't have to give me any. The same goes for dessert. Now, if I'm there during a birthday party for my client, I may accept a piece of cake, but that's about it.

I do sometimes bring in items that make my job easier, like medicine bottle caps that accept a syringe. (And they only cost about 30 cents each.)

Walgreens and CVS will often give you the inserts for free if you ask. Most major pharmacies have these for their customers you just need to ask.

But this is a great way to have clear boundaries.

[smartnurse1982]

I have spoken with my nursing supervisor,who told me it is out of our hands if the parents do not want to purchase the meds.

Even with an Rx in Nj,there are some meds that are not covered.

This thread has gotten me to really think about what is crossing boundaries.

-I would have never thought accepting food was "unprofessional".

-All of the nurses on one of my cases buy gifts at Christmas time for clients....never thought that was unprofessional.

-I may have crossed a boundary buying basic toiletries for a client,like mouthwash and toothpaste.

Mom does not want us brushing the child's teeth. Child has never been to the dentist.

Can't really tell Mom about brushing the teeth,as cultural practices come into play.

There is a smell coming from her mouth.

Mom does not mind us providing mouthcare with an oral swab.

[elkpark]

Mom does not want us brushing the child's teeth. Child has never been to the dentist.

Can't really tell Mom about brushing the teeth,as cultural practices come into play.

There is a smell coming from her mouth.

Mom does not mind us providing mouthcare with an oral swab.

I apologize for not being a home health nurse and maybe not "getting" this, but why is that not considered (reportable) medical neglect? (And what "cultural practices" preclude brushing your teeth?

[JustBeachyNurse, LPN]

I apologize for not being a home health nurse and maybe not "getting" this, but why is that not considered (reportable) medical neglect? (And what "cultural practices" preclude brushing your teeth?

It is absolutely reportable as medical neglect. There are cardiac risks to neglecting oral care even in pediatrics.

Child, neglect and oral health

Child Dental Neglect: A Short Review

http://mchoralhealth.org/PDFs/issues.pdf

[LeChien, BSN, RN]

Mom does not want us brushing the child's teeth. Child has never been to the dentist.

Can't really tell Mom about brushing the teeth,as cultural practices come into play.

There is a smell coming from her mouth.

Mom does not mind us providing mouthcare with an oral swab.

I would document, document, document. Notify your case manager and document. That is absolutely neglect. You can certainly educate Mom on the risks of not brushing her teeth, and document. Cover your butt.

[elkpark]

I would document, document, document. Notify your case manager and document. That is absolutely neglect. You can certainly educate Mom on the risks of not brushing her teeth, and document. Cover your butt.

Covering your butt is all well and good, but everywhere I have ever worked, nurses are mandated reporters. At what point do you have an obligation to report neglect? Or do you just keep showing up and watch the kid's teeth rot over time? My field is child psych, and we report neglect and/or abuse of our clients all the time. Why wouldn't it be the same in home health?

[JustBeachyNurse, LPN]

Covering your butt is all well and good, but everywhere I have ever worked, nurses are mandated reporters. At what point do you have an obligation to report neglect? Or do you just keep showing up and watch the kid's teeth rot over time? My field is child psych, and we report neglect and/or abuse of our clients all the time.

Mandated reporters who fail to report are still culpable regardless of impeccable documentation if they fail to report.

Smartnurse1982 said they can use oral swabs which may be sufficient if done thoroughly and properly perhaps with 1.5% peroximint if the child can't fully open the mouth, is uncooperative or if sensory defensive to tooth brushing. However it does not seem that adequate care is done with oral swabs which puts the client high risk for other health issues