setting boundaries with pt.'s, appropriate vs inappropriate, HELP!

doingourbest · Jul 14, 2007

You can tell someone where you live without being too specific. If it is an uncomfortable situation you can lie about where you live. I mean, I don't know where you are from, but around here there are a zillion suburbs to name, or you can say no I live about thirty minutes up north, or wherever. I certainly wouldn't say "You don't need to know that". You can maintain boundaries without appearing to do so.

PsychRN-Kris · Jul 16, 2007

Hi all.
I'm new to psych and and so thrilled about it. I do have common sense when talking with my pt's but....
I'm having a hard time feeling comfortable assessing my pt.'s. Assessing for orientation, suicidal ideation, and the little questions like "how are you feeling today", "any concerns i can address for you today?", ect. i can pull off without sounding like i'm scripting. But for those that answer and don't talk much...i sometimes don't know how to probe for info. I feel a little lost. The therapaeutic communication we all learn in nursing school helps but there wasn't a whole lot of that talored to psych even in my psych rotation.
Also with boundaries i'm feeling a little lost. I'm having a hard time feeling it out sometimes and knowing what's appropriate to say or not. I watch some nurses who are very professional and talk about setting boundaries, but then i see their pt. interaction and sometimes they say things and i wouldn't think coincided with "boundaries" so i'm totally confused.
For example...how do you handle....
1. being asked your age?
2. a covertly flirtatious pt.
3. listening and validating their concerns without agreeing with them (ex. the doctor doesn't care about me, i hate being here, etc)
Sometimes i feel like i'm starting to develop a healthy rapport with some, and then they throw a question at me like, "do you live around here". And then i say "you don't need to know that" it comes off as harsh and all is ruined and they don't really share much with me after that. Is there a better way to answer that? IF not how to you recover from that?
Do you guys know what i mean, i know alot is common sense but there is such a fine line sometimes. Any pointers, scripting, ANYTHING would be helpful!!!!!!!!!!!!!!!!! thanks!

Assessing your patient does involve asking questions and a lot probing sometimes. Ask the questions directly and try not to worry that you sound scripted. Part of a good assessment is asking the appropriate questions that need to be asked in order to gain a clear picture. For patient's who do not answer or talk, I may try re-phrasing the questions and if still no response I don't push and later on give things a try. Remember non-answered questions still can give information as to the patient's current state.

Boundaries with your pateint's need to be direct and clear. You need to decide what personal information you are or aren't comfortable sharing, I wouldn't have a problem stating my age, but I certainly would not answer where I live. I always answer with "I don't share that information with my patient's" and a smile. Flirtatious patients or ones who make inappropriate sexual remarks I handle with a simple "That is not appropriate (insert name), please do not do that again." If it continues despite giving re-direction I either remove myself from the area or send the patient to their room for a time out.

purplekath · Jul 17, 2007

It is so important to build rapport with your patients. It humanises what can be a dehumanising experience for them. And it really helps when it comes time to ask the probing and other difficult questions, as well as in laying boundaries. Rapport building starts from the moment they are admitted. So does the assessment process. When someone is admitted, smile, introduce yourself and offer a handshake. Whether they shake your hand back is the first tip about how they are feeling. Offer a little sympathy and offer of help, "sounds like you've had a tough day huh? Let's grab a cup of coffee and I'll give you the grand tour". Be aware of how your face and body language is affecting your patient. They are in a scary place. Eye contact, smiles, nodding, relaxed posture...these are all so important to convey messages that the patient needs to "hear" when they get ready to share what they are going through.

Probing questions: These are questions you need to ask, and they are easier to ask if you have taken the time to build a rapport. You don't have to fire them off like a machine gun - it can be done over a coffee, sandwiched between small-talk, little jokes...just general stuff too. The process is intimidating to the patient, so it is ok to break it up with small talk. Don't be afraid to share bits of yourself as you are comfortable. Eg: If someone expresses a delusion that they are the lead singer of a famous band, you can share the kind of music you like, the last concert you attended etc...then ask a relevant question, "sounds like you have been pretty busy, how have you been sleeping?".

Limit setting: Again the rapport will help. You can share what you are comfortable to share - there is nothing wrong with that. But where you are not comfortable, just say so and move along quickly. If you don't want to share your age, just say something with a smile, "oh, old enough!". Flirtation. Depends how bad it is. If it is just flirtation, just remind them that what they said or did is not appropriate. If it is someone who is delusional about you, believes they are in love etc, it is at this time a genuine feeling to them. I say something like, "I know you feel this way now, but that is a part of being unwell. Feelings like this are quite common, and they don't last ...you'll see." If they are trying to touch or grab you, you need to be quite firm, raise your voice a little, be very clear about what will happen if they persist. With concerns, just mirror what they say, "so you feel like the doctor doesn't care? What makes you feel that way?". You don't have to agree or disagree...you just want to know how they feel.