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A nurse becomes emotionally involved with her dying patients and their families, calling them and taking their calls at home in the evening, relating to them as a friend, subtly fostering their emotional dependency, and effectively sabotaging the work of the hospice interdisciplinary team.
This real life situation, drawn from a hospice Internet listserv, reflects a common concern in hospice: professional staff or volunteers who become overly involved with their patients, crossing professional boundaries and allowing their own emotional needs and responses to cloud their professional judgment. What can you as a hospice manager do to help resolve this kind of problem?
"Boundaries can be a real problem in hospice," says Ron Culberson, LCSW, former hospice social worker and now a consultant with Funsulting, etc. in Reston, VA. "We’re all going to die, and most of us have had personal losses. So on a psychological level, it’s easy to slip into over-identification with our patients and lose our objectivity. A lot that goes on in hospice reinforces that. We cross a big boundary when we go into people’s homes, and in hospice we tend to be more relaxed in how we relate to clients generally," he says. "With caregivers in general, our goal is to help people, and we want them to feel helped. . . . I think we can do that in hospice yet still be clear on our professional boundaries."
"I think it’s a real issue," confirms Tom Grothe, NP, former hospice nurse with Visiting Nurses and Hospice of San Francisco. "Many people come to hospice with an underlying need or urge to be of service. Then the intensity of hospice work and of the moment of death blasts away a lot of emotional boundaries," he explains. "Death creates an honest human connection. People are drawn to hospice who need that kind of connection," Grothe observes.
Susan Mann, RN, CRNH, vice president of medical and nursing services for Hospice Inc. in Wichita, KS, and president of the Hospice Nurses Association, points out that hospice’s fiduciary responsibility to its patients is also at issue. Failure to observe professional boundaries could become a risk management issue or liability for the hospice. She gives an example of a hospice nurse who ended up dating and marrying the spouse of a hospice patient. Because she had control over the patient’s medications, there was a perception that she could have hastened the patient’s death. Perceptions like that could damage any hospice’s reputation in the community.
The challenge for hospice teams starts with recognizing when boundary issues have become a problem. Warning signs, Mann says, include staff who keep secrets, provide services outside of the care plan, need to save or rescue their patients, or have a sense of specialness or uniqueness about their contribution.
Extremes of emotional response, such as crying when they are with the patient, treating patients and families as if they were friends, or trying to control the family are other examples cited in a 1991 article in the American Journal of Hospice and Palliative Care.1
Not giving out home phone numbers to patients is important, Culberson says. "In order to be effective as professionals, you need to have a separate personal life."
"We need to help staff understand their role" and give them a thorough grounding in family dynamics, adds Mary Howell, RN, BSN, regional vice president of Hospice of Northern Virginia in Arlington. "They come to the patient/family at a very vulnerable time. They need to be professionals if they are to help the family cope. The family needs that professionalism, not another family member or friend."
Formal staff support mechanisms such as support groups (see Hospice Management Advisor, June 1997, pp. 66-67) offer a forum for processing issues of emotional involvement with patients. New hospice staff, just learning to deal with the profound issues of seeing so many of their patients die so quickly, will have different support needs than battle-scarred veterans, Grothe says. The team needs to recognize when members are having problems and offer specialized support programming for new staff. But hospices also should realize that boundary issues inevitably will be different for new staff, he explains.
Ethics committees provide another forum for exploring whether essential boundaries are being transgressed. Hospices can provide clear policies, protocols, and standards of conduct for staff, as well as using orientation, inservices, and team meetings to reiterate the importance of these standards. The intake or first team visit to the home is an opportunity to clarify the hospice team’s roles and where these roles end. "It gives families structure, which they appreciate, and helps us to be clearer on our own limits," Culberson observes.
Hospices also need clear policies on what gifts from families are acceptable. Cash gifts may need to be redirected as a contribution to the agency, if the family agrees, or else declined. Hospice of Northern Virginia struggled over the seemingly innocuous issue of giving Christmas presents to the young children of a hospice patient. When the patient died just before Christmas, the hospice found itself in an awkward situation with its gifts. "To fulfill our need to do something good at Christmas, we’ve started collecting for Toys for Tots, instead," Howell explains.
"It’s a continuous kind of thing and requires an agency culture that protects staff," she adds. "Sometimes experienced staff will pull someone aside and say, You don’t want to go there.’ It’s also something that people just have to work through. The thing that ensures longevity in hospice is understanding that the nature of this work is being able to make the best of a bad situation and to help families through this bad situation without feeling sorry for them," Howell says.
Burnout is a manifestation of the failure to learn and practice professional boundaries, Grothe says. "Many people in hospice give a lot and honestly grow. If you do, you get what you need and move on, or else, you learn to back off a little. Hospice workers who have done it a long time tend to look a little more distant," he concludes.
"I’ve never been one for saying Never do this, never do that.’ You have to do what seems right at the moment, and sometimes you are going to overstep boundaries."