patient stories, travel nursing

The Freedom of Boundaries

 

 

Ever since I can remember, I’ve been a people pleaser.  I don’t know quite where this tendency came from, but I know it affects me as a nurse. I feel personally guilty when I can’t save a patient or when I can’t make a patient happy, even when it’s something insignificant like their food is cold or I make my perfectly capable patients wear their own shoes to the bathroom instead of giving out hospital socks. I say, “I’m sorry” more as an introduction than an apology.

As a new nurse, I struggled (and continue to struggle) with saying no and setting boundaries, even on extremely manipulative and aggressive patients who needed set limits. One particular patient stands out.

I was working in the stepdown area of a medical ICU in Connecticut as a travel nurse just as I entered into my second year of nursing. I think I was paired with this particular patient because the core staff just couldn’t take him anymore. Ernesto was 70-something man who had essentially killed his liver with a lifetime of polysubstance abuse and Hepatitis C who refused to use his call light, moaned constantly for pain medications, and referred to me as “Mommy.” Yes, a man who could have been my grandfather was calling me “Mommy” all shift.

I was going bonkers.

I tried to make him happy. I explained the call light multiple times, explained my rational for holding off on pain medications, told him my name which was not Mommy. I gave him fresh water, walked him to the bathroom, gave him his privacy as he wanted it, and even broke down and gave him pain medications even though I didn’t think it was medically necessary.

I tried to empathize. I pictured my dad in that bed, my grandpa in that bed, my brother in that bed, my nephew in that bed. I tried other ways of managing his pain. I explained how a lot of it was probably related to constipation. I gave him medications to help with constipation. I spent a good chunk of time in his room, making sure he understood. And after many draining minutes, he’d verbalize that he did.

But minutes later, he’d moan for “Mommy.”

I tried to be compassionate. I forced myself to stare at him, picturing how God loved that man just as much as He loves me and would have died for him and only him.

But then he whined for fresh water just as another patient on the floor was actively coding.

I broke. I yelled, “No! You need to wait, Ernesto!” as I gowned up into the code. Even though I was completely enthralled in the code, I couldn’t help but feel a pang of guilt that I had yelled and that I hadn’t made my  patient completely happy.

After the code as my heart rate started to slow and the adrenaline wore off, he moaned again, and we continued to play the same game all shift long.

Hello. My name is Marissa, and I’m a recovering people pleaser. 

I wish I would have set more boundaries with him. I could have said, “No, you have water. You can have water again when that runs out.” Or “No, you had pain medications, and they’re not helping you. Too, if I give you more, you’re just going to hurt more because you have a giant poop ball in your colon you need to squeeze out.”

But I didn’t. Why? Because I know he’s not going to be happy about it.

As health care professionals, we struggle with a need to be liked. We want to be admired, respected, appreciated, just like any other human being. Since our primary concern at work is with patients, we want to be liked by them as much as we try to deny it or pretend we don’t care.

Right now in health care, our inherent need to be liked is at a new breaking point. Our patients’ satisfaction with our care is now being tied to our hospital reimbursement and therefore our paychecks. Hospitals and their workers are being graded on how happy our patients are on a Likert scale of 1-5 where 5 is always, and we always strive for a 5. It’s a completely unrealistic expectation on a group of inherent people pleasers, and frankly, it’s a disaster to actual patient health. High satisfaction scores are linked to increased costs and increased mortality.

But yet, we ask: Were staff always friendly? Was your pain managed? Did people always explain everything that was going on? Was it always quiet at night? Was the food always warm?

But the truth is, if patients received actual good care, they are going to answer no to one of those questions. Your nurse sternly told you that you needed to get up after surgery to prevent clots in your legs and get you home sooner. Staff wasn’t always friendly. You’ve had chronic pain for years, even going to specialized pain clinics, and now your pain receptors cannot take in the extra medication the doctors ordered. Your pain wasn’t controlled. You were so in shock over your new diagnosis that no new information was sticking. People didn’t always explain things in a way you could understand. The room across the hall had a late night admission who coded hours later and needed a specialized team to talk at whatever volume they needed to ensure your neighbor survived. It wasn’t always quiet. The food you got was delayed because you weren’t allowed to eat before a scan. It wasn’t always warm. 

Ok, I exaggerate. The warm food thing isn’t actually a question on these surveys that grade hospitals, but did anyone ever stop to ask if we’re asking the right questions?

Did you survive your stroke enough to maintain enough function to fill out this survey? Did your late night assessment catch a significant change and ultimately save your life? Heck, did you follow all the recommendations you were given?

The huge danger of grading hospitals and personnel is that you’re essentially grading a group of people pleasers against an impossible standard. Even in the most ideal hospital stay, it’s not always going to be quiet. It’s not always going to be comfortable. It’s not going to be pain free.

That’s the way it is in medicine. We hurt to heal, and we try our hardest not to hurt you more than we have to, but that doesn’t mean it doesn’t hurt.

Innately, an experience at a health care institution is going to be upsetting. I have to poke you for an IV or labs. I have to tell you to get out of bed, even though you feel horrible. I have to re-explain the bad news the doctor just delivered because you didn’t quite understand it. I have to wake you up in the middle of the night to assess you. I have to explain your discharge instructions, even though you’d love another day in the hospital. I have to let you sit alone with your feelings because my other patient down the hall has more pressing physiologic needs than you do.

A lot of us health care professionals are inclined to blame surveys for exacerbating our people pleasing tendencies. But we need to look at ourselves and how we set boundaries. 

Patient satisfaction surveys didn’t drop out of the sky! They started in the 1980s when businesses decided to survey customer satisfaction, and hospitals decided to jump on that bandwagon. The Centers for Medicare and Medicaid decided to have a national survey linked to how they reimburse in 2006, and here we are! At any point, we health care providers could have started a rallying cry saying, hey! It hurts to heal! This survey is unrealistic and a horrible idea! But no, we just whine and ultimately go along with it instead of putting up a fight. At least the junior doctors in the United Kingdom are going on strike! We Americans are just pouting at this point.

But it’s not that the British are better at boundary setting than Americans. The NHS is just putting more unrealistic demands on their providers than our current American set up. In general, regardless of nationality and culture, health care professionals are horrible at boundary setting, and it’s hurting both us and our patients.

Being a health care professional is traumatic. My roommates my first year of nursing can easily corroborate this claim based on the amount of times I came home crying or upset. It’s near impossible not to lose your faith in humanity in this job. You see abuse, violence, pain, heartbreak, poverty, and everything else awful in the world. It’s  all encompassed in the patient right in front of you, and you can’t run away.

But you can disconnect to become burnt out and bitter.

Compassion fatigue and burnout is becoming increasingly common as we health care professionals are continually expected to do more care with less resources. The world’s population is aging, providers are retiring, expenses are increasing, and the providers entering the field cannot match the demand. Health care is becoming an increasingly demanding job.

But part of the reason it’s so demanding is we’re not demanding what we need.

I think it’s going to take hospitals shutting down, workers going on strike, and patients dying for the general public to understand health care is a scare resource. Sometimes providers are in short supply, just like organs and drugs. We Americans don’t like to admit we can’t have everything we want, but when it comes to health, you can’t have everything you want. Someday, your body is going to fail you, and you will die. To expect anything else is unrealistic.

Furthermore, to stretch us health care professionals to our limit is unrealistic because health care is not an endlessly abundant resource. It’s a growing part of our gross domestic product, last calculated to be 17.1% of America’s GDP. As a reference, education is 5.2%, and military is 3.5%.

Yet even though our country spends trillions of dollars on health care, we health care professionals are still not getting what we need. Community hospitals spent more than $42.8 billion of their own money in 2014 in uncompensated care. Medicaid and Medicare underpay for their services, paying 89 to 90 cents to the dollar for what they owe, leading to a $51 billion shortfall in 2014. Since 2010, hospitals have taken on nearly $136 billion dollars of cuts.

And don’t even get me started on the cost of becoming a doctor and how little residents are paid to basically be indentured servants who work 80-hour weeks. As a nurse, I make significantly more per hour than the poor, overly tired resident doctors I work with. And I think I have more opportunities to pee and eat than they do as well.

Too, patients are demanding unrealistic care.

Maybe it’s my thesis on reasons to withhold CPR that I’m writing for my ethics certification class through the National Catholic Bioethics Center, but I’ve been thinking a lot about futility. However hard it has been to bear the anguish of my patients when the find out they are dying, it has been infinitely more difficult to bear the suffering my patients endure from a prolonged life dependent on machines in the name of futile interventions.

Again in Connecticut, one particular patient stands out. I was paired with this particular patient because the core staff just couldn’t take her family anymore. Cynthia was 90-something woman who had very contracted limbs from 5 previous strokes who could not communicate verbally, breathed through a trach in her neck, ate through a G/J-tube in her abdomen, and peed through a Foley catheter in her urethra. She was treated more machine than human, and her daughters (who had been investigated by the state for elder abuse and most likely had undiagnosed Munchausen by proxy) demanded she have everything done. Including vasopressors to support her dropping blood pressure. Including a ventilator to force her to breathe. Including chest compressions on her frail chest if her heart were to ever stop breathing. Including getting rectal temperature every four hours because “it was the most accurate.”

Cynthia was in the hospital yet again (and probably less than 30 days from previous admission, so who knows if the hospital was getting paid!) for an infection in her lungs. I had poor Cynthia for a mere 3 hours before transferring her to a different unit. Her daughters were not present, but I had to tell one of them she was transferred.

She asked if I had gotten a rectal temperature. My co-workers had told me to lie to her, but I didn’t think that was right. I said no. No, I got an axillary temperature in her armpit. She showed no symptoms of a fever, and it was not necessary to get an invasive temperature.

You would have thought I stabbed the woman. Her eyes looked absolutely sinister, and it took 15 minutes of arguing and her threatening to report me and me talking her down for her to go to her mother (who was still alive and afebrile).

Cynthia is an extreme case of the unrealistic demands that patients and family members can make, but so often do I see patients and families who ask for everything and then aren’t there when everything is done.

But you know who is? I am. We health care professionals have to live with the decisions and perform the decisions patients make, and it can be an internal torture.

I see the pain of Q8 hour heparin shots to prevent blood clots. I see the anxiety of being unable to breathe on your own and having to coordinate yourself with a machine. I see the anguish of being unable to move because of all the various tubes in and out of your body. I hear the whimpers and cries as I draw blood and place IVs. And worst of all, I feel the cracked ribs and see blood coming out of facial orifices during chest compressions.

And that is a much worse trauma to my soul than breaking  and reinforcing the bad news that you are dying.

I don’t know when it started, but all of a sudden, death is seen as a medical failure. It’s an absolutely absurd claim. People are going to die, and only certain deaths are medical failures, like when a pulmonary embolism (a clot in the lungs) is undetected and untreated. But someone dying of old age is not a medical failure. Someone dying of cancer is not a medical failure. Someone dying of a disease is not always a medical failure. We’re all going to die of something, and to treat incurable diseases with curative medicine is abuse disguised as medicine.

Long hours, increased demands, less resources, more useless suffering, and a tendency to favor what the patient says no matter how misguided over the educated professional?  Is it any wonder we’re all so burnt out?

Burnt out is why I travel nursed, and in that time, I learned to ask for what I needed. As a travel nurse, no one is looking out for you. Your company wants you to make them money. Your hospital isn’t invested in you. No one cares about your needs, so you need to ask for them.

I learned to demand stipends for parking, certifications, scrubs, the basics of what I needed to do my job. And it was frightening to be so demanding, and I didn’t always get everything I wanted, but I always go what I needed.

And in getting what I needed for work, I learned to get what I needed from work. My contranct paid me less than I made as a ceritified nursing assistant to pick up hours, so I took advantage of my time off. I did things I wanted to do in my college town that I never did because I felt like I needed to see my friends, pick up extra, volunteer, and otherwise do those things people say you have to do. I had no demands on my time, so I learned what I liked to do, like writing, reading, exploring, attempting to be good at photography, and other things I enjoyed. More than that, I learned I needed time off from work to be ready for work. I learned I needed significant time alone to be a good friend to others. I learned what I needed, and I learned to ask for what I needed.

And in setting boundaries and learning my boundaries, I rediscovered my compassion for health care. As the brilliant Brené Brown wrote:

“Compassionate people ask for what they need. They say no when they need to, and when they say yes, they mean it. They’re compassionate because their boundaries keep them out of resentment.”

–  Brené Brown, Rising Strong

I had no idea how resentful I was becoming. My friends and co-workers probably didn’t see it, but I could feel resentment building inside of me before I travel nursed.

To to this day at work, I feel resentment building. Sometimes it’s the patient demanding narcotics who’s on the call light constantly. Sometimes it’s the patient demanding a millions scans and blood tests. Sometimes it’s my co-worker who is treating my patient more like a physiologic machine than a person. Sometimes it’s me whining to myself.

It doesn’t matter what it is, but I find to keep my compassion, I have to set my boundaries. I have to say no to my patients, my co-workers, and even myself.

We need to ask for what we need to remain compassionate.  But at the same time, we cannot say no to everything or we risk becoming bitter.

It’s no secret I’m a softie. My nephew asks me to read the same book 5 times, and by round 5, I’m annoyed, but I love the kid so much, I’ll do it to make him happy. A lot of patients ask for water when they can’t have anything to drink, and some of the time, I’ll slip them 9 ice chips because I know it won’t hurt them and it’ll make them happy. Sometimes, saying yes when we want to say no is good for us too.

So, how do we balance it all?

Aristotle has a moral theory called The Golden Mean where “virtue is the golden mean between two vices, the one of excess and the other of deficiency.” We cannot be too kind and give everything we have to excess where we become burnt out, but we also cannot be too stingy and give nothing that we could give to the point of scarcity where we become bitter. We need to set boundaries as we set demands, having the two balance one another out in order to find the virtue of compassionate care.

It is from the paradox of the Golden Mean that I found how to make my patients happy. I decided it was not my job to make my patients happy. I blatantly refuse to waste my energy on concentrating on my patients’ happiness. I concentrate on their health and wellbeing, on treating them with kindness and respect, on answering questions in a way they can understand, on taking my time to show my care, on sitting down and taking a minute, and explaining my rationale for everything. Most of my patients are perfectly happy with their care. And the ones who aren’t usually are upset that they can’t manipulate me into giving them “that one drug that starts with a D” aka dilaudid aka a narcotic.

When boundaries are set and the patient doesn’t like them, I’m not liked either. And that’s painful for me. I want to be appreciated. I want to be admired. I want to be liked. Setting boundaries is hard because I’m not going to receive what I want out of our interaction.

But I’ve found setting boundaries is the most essential thing I have ever learned as a nurse. And that’s the hardest lesson I’ve had to learn as a nurse: I can’t please everyone. Some people are always going to want more from me, and more than I can give both emotionally, physically, and medically. I cannot give what I don’t have, and I’ve slowly been learning to show myself the compassion and empathy I show my patients.

That means forgiving myself for the times I cannot please people. Yes, maybe I could have talked to my 70-something man in a more respectful way. I will fully admit that I could have handled that better, but I can’t please everyone. Despite my best efforts, he was never going to be happy with my care because he was always going to want more narcotics. And that’s OK. I gave it my best, my imperfect best effort, and that’s all I could give. It’s OK that I couldn’t give more because I had nothing else to give away.

Yes, maybe I could have talked to my 90-something woman’s daughter in a more respectful way. I will fully admit that I could have handled that better, but I can’t please everyone. Despite my best efforts, she was never going to be happy with my care because she was upset her mother was dying. And that’s OK. I gave it my best, my imperfect best effort, and that’s all I could give. It’s OK that I couldn’t give more because I had nothing else to give away.

If people aren’t happy with our best effort, there’s nothing that we can give that’s going to make them happy. And if we are not happy with the best effort that others give us, there’s nothing that others can give us that’s going to make us happy.

In case you’re curious, Ernesto survived. He recovered. He healed physically. I’m sure his survey will show that he wasn’t always treated with respect and his pain wasn’t always controlled. However much his stay was imperfect, he got to leave. Not everyone is that lucky. I’m sure Cynthia wasn’t. I don’t know how it happened, but I’m sure she’s died. I just hope not after some futile CPR that her daughters demanded.

Our job in healthcare is to heal, and sometimes, that requires that we and our patients hurt. It’s going to be messy. It’s going to be imperfect. And that’s OK. We’re human. We’re messy and imperfect, and that’s OK.

As hard as it is to do, we need to set boundaries on our love. I don’t have it all figured out for myself, and like this post, my battle to set boundaries is messy and imperfect, but it’s the best that I can do. Yet, as good as it has been for me, it feels so anti-Christian! Set boundaries on love? What would Jesus do!?

Um. Set boundaries. He’s kind of the master of it.

How many times in the Bible does it say that Jesus went off alone by Himself to pray? How many times in the Bible does Jesus say, if you want to be my disciple, you must do this. How many times does Jesus lay out exactly what His teaching is and then is just like, Ok, leave if you want, this is my teaching. 

My favorite example of Jesus setting limits is at the end of John 6. Jesus had just fed 5000 people, casually walks on water to save his poor apostles, and on the other side of the lake, the crowd is all coming after Him because they’re poor, hungry, and desire bread. Jesus tells them you’re not looking to follow me; you want bread. If you want to follow me, you must believe that I am the bread of life and partake of me. The crowd wasn’t having it. They left. The disciples said the teaching was hard, and Jesus well, that’s what it is, and they left. Finally, it’s just Jesus and the twelve.

Jesus then said to the Twelve, “Do you also want to leave?” (John 6:67)

Jesus had a crowd of 5000 dwindle down to 12, and He still isn’t changing what He’s teaching! Instead He asks, well, do you want to leave too? 

The frightening thing about setting boundaries is that the people might leave. Our fear of loneliness is all of a sudden tied to our innate desire for love, and it is utterly paralyzing to think someone we love might leave us. We want to be respected, admired, appreciated, and otherwise loved, and so we are deathly afraid of setting boundaries on that love because if we do, the possibility exists that the other person will not accept our demands and leave. But if they stay, and our boundaries are trampled upon, is that really love?

But we need to embrace the possibility of the other leaving. This other, no matter how wonderful, cannot love us perfectly. Moreover, we are perfectly loved by the Father who will never leave us. He will, however, set boundaries on His love.

Jesus set boundaries on His boundless love all the time! Honestly, I wish I were Thomas Aquinas and could explain that, but the idea of conditions on unconditional love is real, and I have no clue how to explain it. All I know is that loving parents put limits on their children out of love for that child, and even if she disobeys, she is still loved. Therefore, I know that I am loved endlessly, even if the Lord puts boundaries in place for me.

My two-year-old nephew Sweet Pea has no qualms about saying no. He says no to most everything and is not afraid to demand what he truly desires, even if that thing is the last bite of cookie that’s already in my mouth and he wants to eat it. Obviously, being two, he does not get everything he wants. He’s a mad man, and to give him everything he demanded would not be good for him in the least!

Yet, I greatly admire his fearless demands. He is absolutely confident when he says no, and he has no fear that his demands will decrease how much he is loved. And in truth, nothing can change how much I love him or how much I want what’s in his best interest. Not a hissy fit, not screams, not cries, nothing. I love him unconditionally, and yet, I set boundaries on my love.  Setting boundaries on our love for one another is essential. Our Father does it to us, and out of love, we need to do it to ourselves and one another.

Setting boundaries can start with something small! Honestly, I learned a lot about setting boundaries recently having completed a Whole30. It’s a clean eating diet, and I had to say no to alcohol, dairy, legumes, grains, and almost all additives. As I asked my friend who recommended it, people asked me, “What can you eat?” A lot! Fruit, vegetables, meats, and a lot of really good recipes. Even though it was very restrictive, I could eat any listed food freely, and I found “food freedom” as the authors claim.

When we place boundaries on our love, we will find inner freedom. Boundaries free us from resentment and bitterness, opening up us to give and receive love more freely and unconditionally. When we place demands and conditions on our love, our hearts and minds are closed to receiving love that comes as we do not expect it. Unconditional love receives unexpected joy, peace, and unhappiness.

Unconditional love has boundaries. I’m imperfect and cannot explain it perfectly, but for love to be love, it must have boundaries. For forgiveness to be forgiveness, you must admit a wrong was committed. So too for love to be love, it also must have boundaries and be able to recognize a violation of that love.

This post has been long, messy, and imperfect, much like finding my way to set boundaries in my own life, but I’ll end with words from someone much wiser than I:

When people show you their boundaries (“I can’t do this for you”), you feel rejected. You cannot accept the fact that others are unable to do for you all that you expect from them. You desire boundless love, boundless care, boundless giving.

Part of your struggle is to set boundaries to your own love – something you have never done. You give whatever people ask of you, and when they ask for more, you give more, until you find yourself exhausted, used, and manipulated. Only when you are able to set your own boundaries will you be able to acknowledge, respect, and even be grateful for the boundaries of others.

In the presence of the people you love, your needs grow and grow, until those people are so overwhelmed by your needs that they are practically forced to leave you for their own survival.

The great task is to claim yourself for yourself, so that you can contain your needs within the boundaries of your self and hold them in the presence of those you love. True mutuality in love requires people who possess themselves and who can give to each other while holding on to their own identities. So, in order to give more effectively and to be more self-contained with your needs, you must learn to set boundaries to your love.

– Henri Nouwen, An Inner Voice of Love

 

 

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