Boundaries and Self-Care

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Boundaries and Self-Care

• Integ?Net Employee Assistance Program (EAP)
• 1-800-458-8183

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The challenge...

• Providing care can be an emotionally
• complicated process. It requires the ability
• to be meaningfully related to a patient and
• family yet separate enough to distinguish
• ones own needs.

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Why an Issue?

• Hospice volunteers are caring people and want to
  do what is best.
• In hospice work, boundaries can easily become
  blurred due to the nature of what care is
  provided and the setting (in patients homes at
  times and in their world).
• The population served is vulnerable and may not
  be aware of interpersonal boundaries.

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Why an Issue?

• As patients and families face end of life issues,
  signs of intimacy may appear. Patients and
  family members often want to talk about really
  personal issues. This could be interpreted as an
  invitation to friendship.

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Professional Boundaries

• Defined as limits that protect the space between
  the caretaker's power and the client's
  vulnerability.
• Maintaining appropriate boundaries safeguards
  both the patient and the caretaker by controlling
  or limiting this power differential.
• This boundary setting allows for a safe
  connection between the caretaker and the patient
  based on the patient's needs.

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Professional Boundaries

• Boundaries in Patient care are mutually
  understood, unspoken, physical and emotional
  limits of the relationship between the trusting
  patient and the caretaker.
• A caretakers boundaries represent a set of
  culturally and professionally (even for
  volunteers) derived rules of how health care
  providers and their patients interact.

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Professional Boundaries

• Fiduciary Responsibility best interest
• Therapeutic Relationship zone of helpfulness
• Boundary Crossing across and back with no
  long-term harmful effects
• Boundary Violation harm to the patient
• Violation Potential risk factors

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Be aware of

• Any applicable Licensing/Certification Code
• Any professional Ethical Code or Standards of
  Care
• Organizational Policies and Procedures
• Training needs
• Self

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Zone of Helpfulness

• Therapeutic or professional boundaries
• allow a safe relationship with the client based
  on the clients needs
• produce consistency and predictable behavior
• define how power is exercised within the
  relationship
• protect the client in the relationship
• protect the caregiver in the relationship

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Professional vs. NonprofessionalRelationship

• PROFESSIONAL (including volunteers)
• time-limited
• location defined
• goal-directed
• unequal power
• caretaker responsible for the relationship
• formal training
• PERSONAL
• may last a lifetime
• location unlimited
• pleasure directed
• equal power
• all parties responsible for the relationship
• no formal training

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Goal Empowering vs.Paternalistic

• Empowering...
• is based on a plan of care
• supports and recognizes primary relationships
• supports autonomy of patients
• assists to reveal and explore the full range of
  options and choices
• collaborates with treatment team
• Paternalistic
• assumes needs of patients
• replaces or subverts primary relationships
• fosters dependency
• undermines confidence by conveying that
  patients are incapable of making own decisions
• limits choices
• sabotages efforts of treatment team

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Examples

• Sharing personal information
• Not seeing patients behavior as symptomatic
• Nicknames/endearments
• Touch
• Unprofessional demeanor
• Gifts/Tips/Favors
• Over-involvement
• Romantic or Sexual Relationships
• Secrets

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Your examples
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Causes of boundary issues

• Personality styles or behavioral health issues
• Stress/burnout/compassion fatigue
• Cultural misunderstandings
• Lack of training
• Other?

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Warning Signs ofOver-involvement

• Thinking of patient or family away from duties
• Spending free time with patient or family
  sharing home phone number
• Sharing personal information or concerns with a
  patient or family
• Being defensive about care
• Secretive behavior
• Gift giving to individual
• Inappropriate physical touch loaning or
  sharing personal items
• Feeling so strongly about situation that cant
  hear feedback from team not remaining neutral
• Feeling responsible if patients progress is
  limited
• Feeling possessive about a patient or family
  (super caregiver, or you and me against the
  world)
• Other?

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Safeguarding

• What is my role? What is the plan of
  care/goals?
• Would I say or do this with another caretaker
  present?
• Would I document this interaction or
  intervention?
• Does my behavior with this patient differ from
  my behavior with other patients?
• What else could I do to help the patient
• reach these goals without me?
• Potential benefits?
• Potential harmful effects?
• Seek consultation
• Other?

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Decision Tree

• See second to last page of the handout

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Relationship BetweenBoundaries and Self-care

• generally the reason for poor boundaries
• is limited awareness or fulfillment of
• personal needs. The caregiver tries to
• meet his or her needs through contact
• and relationships with families.

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Self-care...

• Accept that there are things you cant fix
• Practice relaxation
• restorative breathing
• repetitive exercise
• meditation
• Humor
• Social supports
• Healthy choices
• moderation (eating, alcohol, spending, etc.)
• exercise
• good nutrition
• adequate sleep
• Other?

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What is Compassion Fatigue?

• Compassion fatigue is thought to be a combination
  of secondary traumatization and burnout
  precipitated by the care delivery that brings
  health-care professionals into contact with the
  suffering.
• Szabo, B. (2006). Compassion fatigue and nursing
  work Can we accurately capture the consequences
  of caring work? International Journal of Nursing
  Practice 12 136142.

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Difference between Compassion Fatigue and Burnout

• "Compassion fatigue is when caregivers have such
  deep empathy they develop symptoms of trauma
  similar to the patient according to director of
  the Army Institute of Surgical Research Col
  Kathryn Gaylord.
• The disorder can also resemble burnout which
  occurs when emotional exhaustion is experienced
  due to increased workload institutional stress
  does not involve trauma
• Compassion fatigue can have detrimental effects
  on doctor-patient relationships since doctors
  suffering from the disorder often either grow
  distant from patients or get too close
• Wilson, E. (2008). New Program Offers Care for
  Caregivers. Department of Defense Military Health
  System News, 23 May 2008.

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Secondary Traumatic Stress

• People who come into continued, close contact
  with trauma survivors may also experience
  emotional disruption, becoming indirect victims
  of the trauma.
• The natural, consequent behaviors emotions
  resulting from knowledge about a traumatizing
  event experienced by a significant other.
• The stress resulting from helping or wanting to
  help a traumatized or suffering person.
• Bride, B. (2007). Prevalence of Secondary
  Traumatic Stress Among Social Workers. Social
  Work 51(2) 63-70.

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Compassion Satisfaction

• Compassion satisfaction is the ability for
  clinicians to derive a great sense of meaning
  purpose from their work.
• It may aid in alleviating existential terror
  endemic to the human condition when a society is
  at war.
• It may be an important buffer in managing and
  transcending alterations in belief systems, and
  physiological or emotional reactions seen in
  compassion fatigue.
• Stamm (1999 and 2002) as quoted in Tyson, J.
  (2007). Compassion Fatigue in the Treatment of
  Combat-Related Trauma During Wartime. Clinical
  Social Work Journal 35183192

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Major factors contributing to Compassion Fatigue

• Poor self-care
• Previous unresolved trauma
• Inability or refusal to control work stressors
• Lack of satisfaction for the work
• Figley, C. R. (Ed.) (1995). Compassion fatigue
  Coping with secondary traumatic stress disorder
  in those who treat the traumatized. New York
  Brunner/Mazel.
• Other?

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Predictors of Compassion Fatigue among Hospice
Nurses

• Trauma
• Anxiety
• Life demands
• Excessive empathy (leading to blurred
  professional boundaries)
• Abendroth, M. Flannery, J. (2006). Predicting
  the Risk of Compassion Fatigue A Study of
  Hospice Nurses. Journal of Hospice and Palliative
  Nursing 8(6) 346-356.

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Characteristics of clinicians experiencing
Compassion Fatigue

• Physically Chronic sense of exhaustion and
  fatigue, insomnia, headaches, stomach aches, lack
  of appetite, physical agitation or retardation,
  frequent bouts of sickness (e.g., colds, sore
  throats).
• Psychologically Often feel irritable, are
  overwhelmed by the volume and content of their
  work.
• Relationship with Clients Sense a reduction in
  their baseline empathy for others, feel numb to
  patients and families pain, are cynical
  regarding clients ability to change and/or
  perceive them as being responsible for many of
  their problems.
• Organizationally Often report a sense of feeling
  scattered and unable to meet their professional
  personal obligations.
• Mendenhall, T. (2006). Trauma-Response Teams
  Inherent Challenges and Practical Strategies in
  Interdisciplinary Fieldwork. Families Systems,
  Health 24(3)357-362.

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What You (and volunteers) Can Do

• Recognize the symptoms of compassion fatigue
• Learn to ask for help
• Be aware and accept the limitations of your
  family, your job, and yourself
• Maintain discipline in daily responsibilities and
  duties
• Take time out during the day
• Take short vacations at least twice a year
• Try to change little things that gnaw at you and
  accommodate to those you can't change
• Organize your time so you can concentrate on
  vital tasks
• Admit compassion fatigue is a real problem for
  you and don't try to cover it up
• Distinguish between stressful aspects of your job
  or home life that you can change, and those you
  can't change change what you can
• Other?

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What clinicians need to ward off Compassion
Fatigue

• Boundary maintenance
• Self-care
• Good training
• Good supervision
• Radey, M. Figley, C.R. (2007). The Social
  Psychology of Compassion. Clinical Social Work
  35(1)207214
• Other?

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What leaders/organization can do

• Identify realistic attainable goals for each
  department and evaluate accordingly
• Help staff to maintain personal growth both at
  home and on the job
• Encourage and support staff to develop an active
  outside life with a variety of interests
• Encourage staff to personalize the work
  environment with meaningful pictures, objects,
  colors, etc.
• Encourage staff to be comfortable with themselves
  by setting limits how far to become involved with
  clients and colleagues
• Encourage and practice good communication skills
  on the job
• Provide for flexible working conditions on the
  job
• Encourage trying new ideas outside of the box
• Sponsor decompression techniques activities
  such as meditation or exercise that relieve
  tension and put staff into a more relaxed state
• Build support systems among staff to discuss
  problems and help each other look for solutions.
  Don't just air gripes - look for solutions
• Other?

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Thank you

• Comments
• Questions
• Scenarios
• Sounds good but