Boundaries in pediatric PDN/home health

  1. Scenario: young child has 16h/day x7days a week including school hours. A team of 4 nurses cover the shifts some full time others part time. Family is welcoming (including siblings) and have come to appreciate the assistance and care of skilled nursing. Two nurses are working on the day of child's birthday party. Party crosses between two shifts. Mom feels guilty that the other two nurses won't be there as they are scheduled off so casually invites them. ( more so because she doesn't want hurt feelings to impact her child's care as is a common fear of parents of medically complex children ). Child has been under agency care for several years. One nurse has been with the child since start of care. Newest nurse on case has been with child 3 months.

    Clinical manager explains to nurses orienting to case that parent feels obliged to invite nurses to family celebration but traditionally and ethically all decline and only nurses scheduled to work attend.

    Nurse A& B are working. Nurse A (the longest on case nurse ) brings a card. & token gift (something home made. & personalized, low out of pocket cost. Item is something child can use. & enjoys). Nurse B brings a card and token gift (say appropriate story book). Both nurses while present at party focus on attending to the child 'a skilled care needs , treatments, medications, etc. helping family & client enjoy celebration without being "obvious" ( as we know a good pediatric nurse knows how to be subtle/ in the background and still get the job done & ensure family has as typical of an experience as they desire. & is possible)

    Nurse C is off as per usual schedule. Has been on case for a few years. Brings a card and token gift next shift worked as (s)he too has a fondness for child. & family. She politely declined the invitation as she does with all off -work requests from clients. Wishes the mom happiness & success in the birthday celebration. Mom understands.

    Nurse D (newest nurse) decides to attend party. Brings one of her own children in same age range as the client & siblings. Brings a card & gift. (Gift is a little more expensive than the other nurses choices but not atypical for the types of gifts exchanged at children's parties in the community) Nurse D participates as a guest in the celebration along with their child. Doesn't offer or perform any skilled care but offers to hold/sit with child. Nurse D feels a "bond" with child/family as a mother with children in same age range as client/siblings.

    Nurses working are a little uncomfortable with nurse D's off the clock presence/ participation in party.

    Nurses who followed agency policy are uncomfortable but not enough to discuss situation with supervisors.

    At next monthly supervisor visit parent makes an innocent comment to nurse manager about the party & who attended. She casually mentioned she was surprised nurse D not only attended but brought her child; ultimately she was glad client had a wonderful time & enjoyed the celebration, Parent is not upset.

    Manager informally speaks with all 4 nurses to reinforce company policy. Notice reminder about gifts & professional boundaries policies is sent to all field staff.

    I can understand feeling like you are friends with the parents/family as you work in closely in a home environment. But we are not. The client's school/home is our workplace. General policy is to wear scrubs and look professional, in addition to wear ID badges when not in home to reinforce the professional image.

    What do you think ?
    Would you attend a patient/family (invited) celebration on your off time?
    What about gifts?
    Do you buy gifts, items that are in excess of official agency policy?
    What about intentionally introducing client/parents to your family? (Not referring to incidental meetings on days off in the community as ultimately this is bound to happen at the store, school, etc and saying this is my child/wife/husband etc)

    Disclaimer....this is NOT about YOU. This is compilation of a few issues I've seen/ heard of occurring in the past few years working private duty pediatrics.
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  3. by   caliotter3
    Inasmuch as one of my agencies would have some of the office personnel as well as the clinical supervisor at attendance at the party, I don't see how individual nurses can be faulted for only doing what their employer not only allows, but encourages. My other agencies would not say a word but they would take action against any nurse that complains about the situation. Individual nurse supervisors, may or may not, pay lip service to "maintaining" boundaries, but their actual action and non-action would give their true professional feelings away.
  4. by   JustBeachyNurse
    Management asked that nurses not attend client parties when off duty. It wasn't a major milestone and office staff was not invited. It was just a kindhearted parent that invited nurses that happened to be scheduled off. I don't think she expected anyone to ever accept let alone bring a child

    Unlike one client who had a major clinical milestone that coincided with a birthday. And nurse who ever worked on the case , management & office staff were all invited and encouraged to attend the big celebration. Different scenario. Major happy event.

    I know there were issues in the past including off duty nurse interfering with client care (on duty nurse was properly caring for client & didn't ask for or need help so it wasn't an issue of safety).

    I know in one case the "extra" visits off duty were an issue for one nurse's ego. Sort of like no one can care for child like me ( including the parents). There was no issue of parent neglect or competency. The parents both worked full time to provide for the family. Skilled nursing cared for the client so the parents could work. This nurse just felt she was the greatest thing since Florence Nightengale and her way was the only way. She felt the parent should quit work & care for the child full time. Very resentful to parents and other nurses. Wasn't until a clinical manager happened to do a field visit for another nurse with the client & the off duty nurse showed up unannounced as usual.
  5. by   mluvsgnc
    I would politely decline any personal invitations (I work in ped HH), and I would not offer/bring any gifts at any time (if it happened on my shift or bringing something the next shift). I believe it's best to keep things as professional as possible, and that it can be done in a nice, tactful manner. If my shift occurred during the party, I would do my best to be as "out of the way" a possible and maintain a professional demeanor while attending to the child. Once boundaries start to blur, things can get complicated and feelings can get hurt.
  6. by   ventmommy
    I would not have invited off duty nurses. Surely they know when my child's birthday is as it's on every piece of paper ever written about him. If they felt so inclined to give a card or small gift, so be it. I certainly wouldn't say a word to the supervisor or other nurses.

    Our nurses had varying attitudes on receiving gifts. One of them went so far as to refuse a piece of cake I offered because she literally was interpreting that as a gift.

    I don't know about meeting family members of the nurse. They aren't bound by HIPAA so then they could say "oh, I met little Johnny and he has blah-blah-blah." I assume that all nurses talk about their cases and they don't use names/locations but if her family members meets the patient, the family member could easily put two and two together and know way more than they ever should.

    It's one thing to see a nurse by accident at the market or mall or bank. It's another to invite her family over.

    I have two family members that are LCSWs. Both do mental health counseling. One works with fathers reintegrating after prison and the other works with hospice AIDS patients. Both have a policy that if you are out in public with them and someone random is like "Oh hi so-and-so....." to them and they do NOT introduce you immediately you should assume it is a client, then you should just smile and step away until the encounter could be ended.
  7. by   nursel56
    To me this scenario reminds me of the unique challenges in PDN. We have to make situation specific judgements on both ethical and medical issues every day.

    It appears that agencies differ greatly in "personality" as well. Some, ike Cali suggested actually encourage boundary crossing, some don't care as long as nobody complains and some are up-front about policy and strict boundaries as appears to be the case here, JustBeachyNurse.

    Since I'm assuming Nurse D was aware of the policy and decided to violate it, she was in the wrong and probably should have been counseled individually and observed carefully for further behavior along those lines.

    It is so valuable to have a harmonious group of nurses it's worth protecting from the disruption of someone who may be satisfying their own need for validation by crossing boundaries in a sort of "the family likes me best" game.

    Now for myself and other nurses I've known I've attended funerals and been on-duty at parties or receptions when off-duty nurses have attended. It didn't bother me because I knew it was a courtesy and didn't strike me as unprofessional - usually these are nurses who had known the client and family for many years and the agency wouldn't take a position on it one way or the other.

    Similarly I see nothing wrong with giving a token card and gift to a child. In the past I've accepted small gifts on occasion, such as a handmade felt turtle pincushion a DD adult patient crafted for each of her nurses. I just wouldn't refuse that. In our line of work appreciative families want to find ways to say "thank you" and so far the items have been small baked gooda or handmade items of little material value.
  8. by   ventmommy
    I think end-of-life situations and funerals are totally different. When we knew that our son was going to die, we asked the agency to contact all the nurses and back-up nurses so that they could come to the hospital and say goodbye if they chose to do so. The funeral was across the country but we had a memorial service when we came back and they were all invited to that as well as the office staff, the DME rep that had been with us from the beginning and came over monthly, the DME RT and some of the hospital staff.
  9. by   JustBeachyNurse
    I know of a client that had a "burning of the g tube" party after the child was 3years GT dependent for hydration & nutrition. Through parent, nurse & therapist hard work with the child, the child was able to transition to PO feeds.

    They invited agency scheduler, management, office staff, any nurse who ever met the child , school, therapists. I think she even invited the UPS guy who delivered the feeding supplies.

    It was a celebration of success.

    Again very different situation than a small party that a parent invites all nurses to out of courtesy.
  10. by   Elle23
    I personally see nothing wrong with attending the birthday party of a client, if the family wishes it.

    I have a hard time understanding what boundary is being crossed.
  11. by   Elle23
    I don't know if my agency has a policy against giving gifts. The only thing I heard in orientation is we are not to receive them.
  12. by   JustBeachyNurse
    One agency has a restriction both ways (can neither give nor receive) the other agency says up to $25 total annually but no cash or gift cards. Includes meals (example out to dinner with patient & family, family chooses to buy the nurse dinner. This value counts towards the maximum Marketing & management are prohibited from giving gifts of any kind. Token gifts are permitted to child/family from first line direct care staff. The dollar amount was recently discussed as token = $10 or less but being clarified by corporate compliance as not specifically stated for field staff gift to clients in the policies/handbook. But trainers/orientation staff have been giving a $10 as clarification.

    The issue in attending in the scenario is that not only did the nurse attend but also brought her school aged child to the client's home. This is considered inappropriate by most boards of nursing. (And was recently cited in the case of the nurse from AZ when reported by Banner Health to the AZ BoN...she brought her brother & child to a patient's home to "wait in the car" and client knew because brother rang door bell asking to use bathroom.

    Attending an event at a client home when not working (but other nurses are on duty) when there was not a relationship prior to the family needing nursing services from the employing agency can be seen as crossing the professional boundaries.

    Some families I could see my being friends with the parents in different circumstances. But I am there as a professional to care for their child,not to be best friends with mom or dad.
  13. by   systoly
    i think this is an excellent topic
    no, I have no desire to attend such events
    the parents of my present patient used to invite
    me all the time
    all the other nurses on the case attend at least some
    of these events
    the parents used to make remarks such as "don't you like us?" etc.
    I respond with something like, "perhaps I don't like you, but I looove you
    for 12 hours three days a week"
    it has never bothered me when the other nurses show up during my shift
    we hardly ever get to meet face to face
    yes, i buy gifts, a sponge Bob wash cloth for a buck here, a t-shirt for $ 2 reduced from $12 there
    i don't buy birthday or Christmas gifts
    the other nurses buy more expensive gifts, but i truly believe they do it, because they feel like it and
    not for personal gain
    the agency, as nursel56 put it, doesn't care, as long as nobody complaints
    no family introduction desired

    if i ever felt that a co worker was invited for any other reasons than
    the family really desiring their attendance, i'd certainly discuss it with
    my co worker
    otherwise, i guess i'm like the agency, i don't care as long as everyone is happy
    (that just occured to me)
    i'll be watching this thread with great interest and maybe rethink some stuff
  14. by   JustBeachyNurse
    I don't particularly care unless an off duty nurse is impeding my ability to care for my patient or if the actions of another adversely affect my job or relationship with the parents. (Not just nurse Sally came but you didn't so don't you like us?). Fortunately this is not an issue with my primary patient or family; or any of the other cases I regularly work with. Nurses have tried to get themselves in favor/friendly but some of the parents and the mom laughs and says "you know that you are getting paid to provide skilled care for my medically fragile child not hang out with me".

    I am in awe of some of the gifts I've seen given from nurse to patient/family in the past year. Gifts I could not afford to purchase myself or family...certainly not but paying for a client or coworker.