Violating Theraputic Bounderies as an RN?

[peaceluvandnursing]

I have only been in psych nursing for 8 months although I have been a nurse for 15 years and recently completed my MSN-Nurse Practitioner requirements. I was recently terminated for the above reason and also denied unemployment. I was pulled to a residential adolescent unit to work as a Mental Health Tech due to DHS ratio requirements. We have very strict rules regarding patients and contraband. These patients are there because they either attempted suicide or made statements of wanting to harm themselves or others. Their safety is our main concern.

A patient I was not familiar with approached me at the staff table and asked me for another paper cup at the evening meal. I asked her where the cup I gave her with her dinner was. She replied that she threw it away. I was suspicious as there was not a trash bag out yet and besides they must ask permission to throw away so we are sure they don't hide anything on their person. I have seen it all and patients often eat things like paper cups, antiseptic wipes, crayons, even pencils. I felt it was my responsibility to be direct with her to be sure she was safe. She started to get defensive. I then noticed that her chest area was all lumpy with hard edges, like she might have hidden things in her bra. I explained to her why I was asking and reminded her of the policy. She continued to be insulted about me asking. I had a pen in my right hand, (I am left handed) and was moving my hands as we talked. I very casually, and without any drama, pointed to the right center of her chest area and asked "What is that??" like I was perplexed, (which I was!). My pen accidently touched her shirt and I heard a "pop", just like Styrofoam. I reported it to the other tech and the nurse assigned to the unit. His comment was "Don't worry about it, she is going home soon anyway". Next day the patient reported it and I was fired, confirmed, they said, on video tape. ( no audio). Reason: She was a male transitioning to female and I violated the therapeutic boundaries of a transgender patient by touching her chest with my pen.with her chest area. The policy they used was "professional standards of conduct" therefore considered misconduct. I have been bullied by this nurse manager since I arrived. I am appealing the unemployment. I cannot find an actual definition of therapeutic boundaries in their manual. What is my defense, do I have a chance of convincing Unemployment this was not misconduct? Professional conduct is defined as "any sexual, emotional, or physical abuse to a patient..."

[Heylove, BSN, RN, EMT-B]

I am so sorry to hear your story. It sounds like one of my worst nightmares, and I don't have any answers for you. In our area of nursing, even with what I believed to be the protective factors of cameras and video recording -- some of our organizations will throw us under a bus in a heartbeat. It is so disappointing.

I hope you are able to resolve the unemployment issue and hope the people that were responsible for your termination can sleep at night. Were you also reported to the state board?

[penelopelp]

That sounds really ridiculous considering you weren’t trying to touch her chest. Part of therapeutic boundaries is that we shouldn’t touch patients unless we are doing it to provide medical care—like checking blood pressure. I’ve worked with adolescents for years and I don’t touch a patient at all without asking. For example, if they ask for a Band-Aid, I ask if they want me to apply it or if they’d rather put it on themselves. That being said, I have brushed up against a patient or two on accident from time to time.

It sounds like this is someone you don’t want to work for anyway. Hopefully you’ll get your unemployment. If you don’t, you can still probably get another job. Just be extra careful in the future—especially with adolescents.

[peaceluvandnursing]

Thank you both. No, I specifically asked about reporting at the time. The Head of HR assured me i was not a DHS reportable offense nor a nursing board issue. It was the DON who made the decision to deny the unemployment.

[Heylove, BSN, RN, EMT-B]

Walk away from that place with your head up high.

[DAL2010]

As a Psych nurse, our standard is that if we believe a patient to be concealing items that are unsafe, we address it with the patient first, then if necessary, we call the doctor to report our concerns, then conduct a skin assessment if doctor orders it. We also require a doctor's order to search patient rooms for contraband.

In your scenario, after the patient denied contraband or seemed insulted, I would have spoken with that patient's primary nurse, who should have spoken with the patient. If primary nurse did not address the situation, I would have taken it to the charge nurse. If neither nurse addressed the situation, I would have contacted the supervisor, who could speak with the patient and/or call the doctor for search orders. (Even though you are a nurse yourself, your actions were limited because you were working as a Tech at this time.)

I actually find it difficult to believe that accidentally & casually waving a pen could impart a great enough pressure to pop styrofoam through a shirt - sorry, but I find your explanation a little light. While I can't say this was fireable, I would say it should have definitely led to education for you on appropriate interactions with patients and appropriate elevation of concerns.