setting boundaries

[NurseNature]

I have one year left to be an RN and in just two more days I will start my new job as a CNA. I have always been a server where the guest is always right no matter what. In clinicals I found that the most difficult part of the work for me was setting boundaries. How will I ever learn that? When is it okay to say "stop" and how do I say so without being rude or making the pt feel uncomfortable also? I cried (in the bathroom so as not to be seen) on my first clinical day b/c of a very mean pt. I know she was not oriented and I realize I shouldn't take things so personally. She rode me the entire day and made it very personal for me. Insult after insult and I finally broke down. So... I know I am going to need to learn a few things about boundaries very soon. Please help! I never want to step on anyone's toes and I always want people happy and I don't know what is okay to say or not to say and when or when not to say it. What can I do??? TYIA.

[jojotoo, RN]

One thing that has always helped me is to remember that I have friends (and family) that love me and that I do not need to look to my patients, peers, boss for friendship. Yes, I do have to maintain professional relationships, but I don't look for personal approval or support at work.

[kmoonshine, RN]

No patient has the right to be verbally, emotionally, or physically abusive. Unfortunately, there are some patients who can be very manipulative and one minute they will be throwing you insults, and the very next minute they'll be apologizing, while adding "can I please have some extra juce, you are the best nurse".

It is very important to set boundaries. The most important thing is to be calm, speak in a firm but gentle tone, and NEVER lose your cool (some people like to upset others, and allowing them to upset you will only feed the fire). Here's some of the things I'll say to patients:

If they are swearing or yelling, I might say "sir/ma'am, you cannot use that type of language while you're here at the hospital", or "please lower your tone of voice", and if they continue, I'll say "I do not respond to swear words and your behavior is unacceptable".

If they say derogatory things to me, I will say "I would appreciate it if you would stop saying such terrible things about me". I also have no problem saying "Your language and behavior will not be tolerated".

I'm in the ED and we often have to put patients in 4-point leather restraints due to violent outbursts (for example, yesterday I had an intoxicated woman shove me and try to punch me, and we had to put her in restraints because she was at risk of harming herself and others). Often, they will say "I am going to sue you", "I'll get you", or "I didn't do anything wrong, get me out of here". I will gently say "tonight you made some choices which have consequences, which is why you are in restraints; I'm sorry you made these choices today". It is important to point out that they were the ones that chose an inappropriate behavior, which is unacceptable. Try not to let things get to this point though.

Smile often, speak calmly, don't allow a situation to escalate. When I was in clinicals I had this really mean patient, and I stood there and let her throw insult after insult until I almost cracked - I looked at her, smiled as big as I could, and said "I hope you have a beautiful day Beatrice", and I quickly turned around and walked out of the room. I couldn't reason with this woman (she wanted me to do something to her that would ultimately cause harm, and when I explained why I couldn't do what she wanted, she became irate).

And just remember: some people cannot be reasoned with.

Make sure to document, document, document!!! I'll write exactly what the patient says; "pt states 'I'm gonna get you you b____' and threw pillow at RN", and I will write what swear words they use. I also will write "RN reassured patient of treatment" anytime I try to difuse a situation.

[mauxtav8r]

As far as tools to get through the day, that seems to be well-covered (redirect, document, etc.). Nicely done all.

FutureNurseLori, this is meant in the kindest possible way: you are simply not responsible for those things.

Think carefully about your own reasons for why you **feel** that you should be responsible for the responses of others and I'll bet that you resolve your intense responses to mean patients.

Your empathy is a wonderful treasure. Keep it. Value it. But remember, in nursing you must balance your own **feelings** with what is best for the patient and how you do your job.

Watch the loved ones who come to the bedside and remember that your patients are having the worst days of their lives. Even though they may be mean patients (today) they may not really be mean people all the time.

[rnmomtobe2010]

jojotoo said it for me. As long as I have my fam. and friends to love and support me, I am a-ok!!!!!

[Natkat, BSN, MSN, RN]

This is a timely conversation.

I had TWO such patients in clinical this week; both abusive and manipulative. It has been a struggle for me learning to deal with difficult patients, but I was doing well until this week - faced with two whose behavior was the most challenging I've encountered yet. I was bringing in a breakfast tray at the same time I was going to do an assessment and asked the patient if she wanted to eat first or have me do the assessment first. She screamed "I DON'T CARE WHAT YOU DO FIRST. I'M TRYING TO WATCH MY MOVIE." The other patient wouldn't cooperate with my exam at all and wouldn't let me do an assessment. She had it in her head that she was supposed to go to surgery, even though there was nothing on the chart that said she was. Then when she didn't go to surgery, she got on the phone and called her doctor, while the RN and I were in the room with her, and told him that we weren't doing anything to take care of her right and to "get me the h*ll out of here." In the meantime she is pushing the call light every 15 minutes (no exageration) for a cup of coffee, another box of cereal, ice for her Sprite, an extra pillow, more towels, pain medication, a blanket, more ice, to change the thermostat, etc.

As soon as my instructor got to my floor, I pulled aside and explained my situation. I asked for her advice on how to deal with this situation. I let her know that I wasn't giving up or asking to be removed. I just needed advice so that I can learn from this challenge because I am sure there will be more to come.

My instructor told me to listen closely to the patients, focus on facts, avoid challenging them directly, and of course document every interaction.

This helped me get over being so nervous. I was able to go back in there and deal with them. What seemed to help most was just listening to them; let them ramble on and say whatever was on their minds. Then I reassured them that we would do what we could to help them; letting me know that their complaints were being taken seriously.....even though they were probably, in my opinion, being unreasonable, selfesh, manipulative; at least outwardly I didn't show it.

It feels so dysfunctional being nice to people who are being mean, verging on abusive. But it worked. While they might not have been completely happy, at least it took the edge off. I gained their trust.

The patients pushed my buttons big time. I'm an adult child of alcoholics so manipulation and abuse can turn my world upside down before I even know what hit me. Knowing this about myself lets me know how to go inside myself and pull out the tools I've learned in recovery for dealing with these issues. Once I remembered that I do have those tools, I could draw on those strengths and get through the day.

Hang in there and best of luck.

[verp]

Thank you so much for your suggestions...I have also recently had a patient who was extremely manipulative and noncompliant...felt as though I used up a lot of energy and time trying to placate him which took away from the care I wanted to give my other patients...at the end of my 12 hour shift I was emotionally and mentally exhausted...don't ever want that to happen again. Thanks again,