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Going Beyond the Zone of a Therapeutic Nurse-Patient Relationship
Patient care is always a part of a nurse’s life, which means that nurse-patient interaction is inevitable. But because the line between therapeutic and social relationships becomes blurry, nurses may find themselves in a dilemma, unable to control the situation and their feelings, and cross the line in the process.
Trust, compassion and mutual respect should rule the nurse-patient interaction so that it is therapeutic to improve the patient’s health, but sometimes nurses fall into temptation, make poor decisions, and disregard professionalism and personal morals. Here are some situations where the boundaries have been crossed in different levels:
- receiving gifts from patients
- doing small favors for patients outside of duty hours (e.g., keeping them company, responding to a neighbor’s
call for help regarding a nursing care they need)
- visiting a patient after they have been discharged just to know their progress
- disclosing a patient’s personal information
- giving the patient personal contact numbers
- inappropriate restraints
- physical and emotional abuse
- sexual misconduct
- dating a patient while still seeking care, or even right after discharge
- having a sexual or romantic relationship with a patient
- sexual advances or suggestions to the patient or vice versa where the nurse consents
- verbal seduction
Of the many instances where nurse-patient relationships become inappropriate, nurses being attracted to patients and then acting on their interest is perhaps one of those behaviors that have early tell-tale signs that they are too close to the edge. Here are some warning signs that necessitate a review of the nurse’s behavior:
- often thinking about the patient even after duty
- spending free time with the patient or spending a lot of time with the patient even if other patients’ needs are
more of a priority
- showing favoritism
- sharing personal information and concerns
- needing to dress more attractively when anticipating interaction with the patient
- asking to be assigned to the patient
Nurses are not the only ones who show their vulnerability. On the other hand, a patient’s behavior can also signal that they are crossing the boundary lines, too:
- the patient demands that they are assigned to the nurse
- they show over-dependence
- they keep asking about the whereabouts of the nurse, or other information from the staff
- they give the nurse special attention, compliments, and gifts
The biggest problem with crossing the boundaries of nurse-patient relationship is that it reduces the benefits of nursing care to the patient involved and the others in their care. It is also clearly a sign of disregard for the Nursing Code of Ethics. These are the reasons why boundary violations are never acceptable.
When nurses find themselves in a situation where they are going beyond the zone of helpfulness, they must be aware of themselves and be quick to review and stop their behavior.
They should seek their supervisor’s help and refer to institutional policies. In receiving gifts, for example, some hospitals will allow small tokens to be received with gratitude right before discharge.
For other behaviors, nurses may check with their respective Board of Nursing and the National Council of State Boards of Nursing. These organizations define professional boundaries and give specific instances where behaviors already are deemed inappropriate.
Nurses also have a duty to report sexual misconduct to the supervisor or the Nurse Manager. These behaviors are never tolerated. Proper documentation must be made, and the misconduct duly reported to the board of nursing, which can take immediate action such as revoke their license.
RNs must also remember that if they became self-aware and educated on professional boundaries, they can prevent violations from harming their patients and their professional career.
Posted: 8/4/2017 11:20:48 PM
Ensuring Patient Safety - 24/7
There is a reason why safety is deemed important to human survival next to air, food, water, and shelter. It’s because it is hard to be healthy when there is injury. Injury and health are like oil and water. They do not mix. Therefore, to be healthy, one also has to be safe at all times.
In hospitals, patient safety is synonymous to positive patient outcomes. The ultimate goal is to cure a patient’s disease or to improve their health while keeping them away from harm at the same time.
The dangers lurking in acute care settings are all too real, and too perilous. It's no wonder almost half of the lessons and training obtained in nursing schools are about safety.
Medication errors, falls, pressure ulcers, misidentification and misdiagnosis of patients, infections, and missed or inappropriate treatments are some of the ways a patient can be injured while they are seeking medical care. Even if safety is a responsibility of all stakeholders, including that of the patient, nurses are on the front line of care and are also active facilitators of patient transitioning. Nurses must, therefore, be pioneers of safe practice.
What can you do as a nurse to embed in one's practice a culture of safety?
1. Keep yourself updated with new scientific findings on safety as well as new institutional policies that prevent patient harm. It is good to practice critical thinking in every aspect of care. The hospital is probably the only setting where asking a lot of ‘whys’ is beneficial.
2. Focus. A lot of errors are made due to doing an intervention while being distracted with other things. Alarms setting off, a physician calling your attention, and having to receive a phone call from the lab, are but a few situations that could keep you off-track and make you miss safety points. It may help to do a mental step-by-step check as you go.
3. Participate actively in patient safety huddles. Huddles are so important when you want to be error-free in a complex environment such as a hospital. Be vocal and precise when you discuss patient care. No gray areas. Never assume. Always seek clarification when needed, however busy you are.
4. Teach. Teach patients and their families how to be safe. Telling patients to be aware if there are medications offered them that are not their usual intakes or just plainly instructing them how to use the call light can help to keep themselves safe. Teaching patients and family alike to ask questions and seek clarifications if unsure about any concern, reminding the family caregiver to keep the wheels of the bed locked at all times, and reminding them to wash their hands before and after giving care procedures will go a long way in preventing patient harm.
Teaching is not limited to patients and their families. Newly hired nurses need all the support they can get to successfully be a part of a team that aims to improve patient health. If you are a senior nurse, be generous with your knowledge and share what you know with the newbies.
5. Be a team player and collaborate. Positive patient outcomes are never a result of a one-man-do-all approach to care. Many errors in acute settings are brought about by faulty communication and lack of collaboration. To prevent errors, information and feedback should flow freely within a team to create a safe care environment. Look for collaboration tools that can address communication needs within and among units.
6. Practice medication reconciliation especially during the transition of patients. If only medication errors were included in the list of reasons for a patient’s demise, it would rank 3rd as the leading cause of death. And as for the ‘7 Rs’ of medication administration, these golden rules apply at ALL times. Remember, right medication, right client, right dose, right time, right route, right reason, and right documentation.
7. Never be too tired or too busy to enforce infection control. Remember that sick people are vulnerable individuals whose immune systems may be compromised. Handwashing protocols should always be followed, as well as the universal and transmission-based precautions.
Safety is always a big deal in every aspect of patient care. To keep patients protected 24/7, nurses must model a culture in which safety becomes second nature.
Posted: 10/24/2016 9:04:45 AM
Nursing Tips: When a Patient Leaves Against Medical Advice
“You can’t make me stay.” Although providers may seem shocked when a patient decides to leave the hospital Against Medical Advice (AMA), the patient is exercising his or her right to refuse recommended care or treatment. In an article for Mayo Clinic Proceedings, David J. Alfandre, MD, reports that about 2% of all medical admits result in an AMA discharge. When a patient leaves AMA, the risk of readmission for the same diagnosis increases, as well as establishing a precedent for future AMA discharges.
Who is most at risk for leaving AMA?
- Medicaid or no insurance
- Young adults
- Lives alone
- Alcoholism or substance abuse
- Psychiatric history
- Additional medical issues
- Family or financial obligations
The consequences of an AMA discharge vary by circumstance. Some patients are ready to leave, while others are quite vulnerable. In Dr. Alfandre’s article, retrospective analysis showed:
- Asthmatics had four times more ER visits and three times more hospital re-admits within 30 days.
- General medicine patients who were hospitalized had an almost seven times the likelihood of being readmitted within 15 days.
- Patients who had myocardial infarctions had a 40% higher chance of death or readmission for another MI within two years.
Nurses are likely to be the first healthcare professional that hears when a patient is considering an AMA discharge. Communication with the patient and the physician can be adequate in preventing an untimely discharge. Asking a patient to wait thirty minutes while you phone the physician or prepare the discharge plan may be enough time to calm an angry patient and allow for an honest conversation. The court has ruled in favor of a hospital using “a reasonable amount of time” to permit routine paperwork and procedure. (Bailie vs. Miami Valley Hospital)
Here are five tips for nurses who may encounter AMA situations:
1. Never threaten a patient by saying that if he or she leaves AMA that insurance will not cover the stay. Insurance will pay for care given up to the time of discharge.
2. Whenever possible, take time to talk with the patient to understand more about the reasons for seeking discharge. Patients sometimes have compelling reasons to leave and alternate care resources can be arranged. Document the conversation.
3. Using your facility’s AMA form, provide an informed consent regarding an AMA discharge. Elements of an informed consent include the patient’s acknowledgement that he or she is leaving AMA; that the risks have been explained and the patient understands; and that the patient knows he or she may return at any time. The patient’s signature indicates refusal of recommended treatment. If the patient refuses, the nurse can sign as the witness and document the refusal.
4. His or her rights to receive full discharge instructions and materials remain the same as other patients. Review the instructions with the patient. If the patient agrees, provide wheelchair or escort service from the unit. Document the events.
5. Psychiatric or violent patients may be retained if they are a threat to themselves or others. In these cases, the hospital may use legal means to keep the patient. Accurate documentation by the nurse is key in the process.
When a patient decides to leave AMA, the nurse can help provide as safe and responsible discharge process as possible. Respecting the patient’s autonomy while providing ethical and compassionate care are important nursing responsibilities.
Posted: 6/23/2016 1:00:30 PM
Is It Time to Start Your BSN?
When you wrote your New Year’s resolutions for this year, didl you include starting your BSN? Maybe you’ve been intending to do it for a while, but something always seems to interfere. Family, money, or other commitments push aside your plans…and suddenly another year has flown by.
Why should you get a BSN?
• You’ll get a leg up in your nursing career. The BSN curriculum can include courses in leadership, critical thinking, and communication. These “non-clinical” courses will be necessary for advancement beyond a bedside nurse.
• You’ll earn more money! Salaries vary by region of the country, but a 2013 Rasmussen College article reported that an Associate Degree median salary was $66,620, while a BSN median salary was $75,484. In just five years, a BSN will earn $44,320 more!
• You’ll be on your way to graduate school and advanced clinical practice. Nurse practitioners, nurse anesthetists, nurse midwives…if you’re interested in any of these, or becoming an administrator, you will need a Master’s Degree or Doctorate.
• More hospitals are requiring a BSN for entry-level positions. While ADN graduates will be able to find jobs, the best paying jobs increasingly demand a BSN.
The good news is that there are more options than ever to help you reach your goal. And depending how long you’ve been out of nursing school, some of your credits can be applied to your BSN. Here are three ways to get your RN-to-BSN:
1. Accelerated BSN Programs. Many universities offer programs that can get you to a BSN degree in as little as 12-16 months. The curriculum varies by school; it can be online, campus, or a combination, along with clinical practicums. These programs are for motivated, focused students who are able to study full-time.
2. Online BSN Programs. If flexibility is a priority, you may prefer to take classes online from an accredited school. You can study on your own schedule, although assignments have strict deadlines and some schools require “attendance” at certain times for student interactions. The timeline for BSN completion can be similar to accelerated programs, but the cost is often less. The key to online success is discipline, because no one is going to remind you that a project is due.
3. Community College Partnerships. Colleges and universities in many states are making it easy for ADN graduates to continue on to get a BSN or MSN degree. Called a “Nursing Partnership” or “Nursing Pathway,” the programs offer discounted tuition and easy transfer of credits to encourage community college students to continue their nursing education. Another benefit is that the programs recognize that the nurses are employed, so students can take a term off, and then return without reapplying.
The Institute of Medicine’s 2010 “Future of Nursing” report recommended that 80% of all hospital RNs have a BSN by 2020. If you are considering pursuing your BSN, there is no better time than now.
Posted: 5/6/2016 10:32:06 AM
Medical Tourism: How Much Do You Know?
As a Registered Nurse, you know that people assume you know everything! They can ask you to diagnose a rash or to predict the next flu outbreak. You may even be asked about the growing trend of medical tourism, which is defined as “travel to another country to seek and receive medical care.” According to the Centers for Disease Control and Prevention (CDC), the most common procedures are cosmetic surgery, dental care, and heart surgery. Almost seven million patients from all over the world will travel to another country each year to seek affordable treatments.
Medical tourism, also called “health tourism,” is not really new. Ancient Greeks traveled to the sanctuary of the healing god, Asklepios. Europeans have always visited hot mineral springs and spas known for their reputations for treating ailments from arthritis to gout to respiratory diseases.
Why do people look abroad for health care? Cost and availability seem to motivate patients to look beyond their own providers. Here are some examples:
• Heart bypass in the U.S. costs about $123,000. The same procedure is $27,000 in Costa Rica; $14,800 in Columbia; or $7,900 in India.
• Face lift in the U.S. costs about $11,000. Go to Costa Rica for $4,500; $4,900 in Mexico; or $3,950 in Thailand.
• In-Vitro Fertilization will cost $12,400 in the U.S. Fly to Jordan or Mexico and pay $5,000; Columbia is slightly more at $5,400; or pay just $2,500 in India.
Of course, you are wondering if the quality and care are the same. In 1999, the Joint Commission launched its Joint Commission International branch. The standards and accreditation processes are the same as in the United States. More than 600 international hospitals are JCI-accredited, with an annual growth rate of 20%. Patients seeking treatment at a JCI facility can be assured of safe and high-quality care. Also, many physicians have studied and trained in the U.S. and other developed countries.
Countries that are actively building and promoting health tourism facilities often include a “health vacation” that allows patients (and whoever travels with them) to explore the country while healing, before post-op appointments.
All may seem good, but as in any medical procedure, patients should always be knowledgeable about their care, as well as be aware of possible risks:
• Facilities provide procedures and services without liability. The standard of care is high, but patients assume all risk.
• Long-distance travel is not for everyone. Going to an unfamiliar country, arranging for an interpreter, and the journey back home can be stressful.
• Should complications develop after returning home, patients may need to visit their local providers. This will require insurance coverage or the ability to pay for treatment.
With the ability for people to travel around the world, medical tourism is likely here to stay. International treatment is estimated to be worth $40 billion a year, with an annual growth rate of 25%.
What can you tell people who ask you about medical tourism? It’s not for everyone, but you can offer them some information and encourage them to do their own research before making any decisions.