Updated on May 7th, 2012 at 11:39 am
An important aspect of professionalism in nursing is the code of conduct, including boundaries of the professional role. In a world where technology such as social media is dissolving the barriers between public and private, boundaries may be difficult for new nurses to understand and enact. This article proposes the use of simulated scenarios as a way to help nursing students practice managing boundaries between professional versus personal relationships with patients and families.
Nurse-Patient Relationship Boundaries
The American Nurses Association’s Code of Ethics for Nurses is an excellent guide for orienting nursing students to appropriate boundaries in the nurse-patient relationship (ANA, 2001). Code of Ethics Provision 2.4 addresses boundaries, stating that nurse-patient relationships differ from “those that are purely personal and unstructured, such as friendship.” Boundaries are governed by the purpose of the nurse’s role, which is “preventing illness, alleviating suffering and protecting, promoting, and restoring the health of patients” (ANA, 2001). The statement explains that, although working closely with patients at vulnerable or stressful times may pose the risk of blurring appropriate boundaries, the nurse is responsible for maintaining professional boundaries at all times. For students, a boundary crossing could be explained as a situation in which the patient starts meeting the nurse’s needs, whether as egregious as romantic needs or as simple as the need to share a personal story, rather than the appropriate relationship of the nurse meeting the patient needs.
Cognitive load theory may be useful in understanding the importance of specifically addressing these types of issues outside of the clinical setting (Greene, et al., 2008). According to this theory, individuals can only attend to three to five units of information at any given time. For a student who, for instance, tends toward a highly emotional relational style, it may be difficult to make the conscious effort to maintain appropriate boundaries when the student also must focus on practicing skills, preparing medications, completing documentation, and other new tasks. Practicing in simulation can help the student recognize warning signs for when a relationship may stray into unprofessional territory. It can also help students develop and practice strategies for addressing potential boundary crossings in a gracious and professional, but firm, manner. Finally, simulation can help students problem-solve difficult relationships, including recognizing when they might need support from an instructor, supervisor, or colleague.
Case Study: Janey
To provide an example of how professional boundaries might be addressed in simulation, this article presents “Janey,” a fictional student with boundary difficulties. In her first clinical, Janey received a warning from the nursing program for an ethical violation. Janey was on a medical surgical floor working with a young, homeless single mother who was recovering from an appendectomy. Janey was moved by the woman’s difficult situation. She told the patient that her church offered services for women in her situation. Janey provided her personal phone number and e-mail to the patient and told the patient to contact her so that she could help connect her with these resources. When this situation came to the attention of the instructor, she spoke with the student. Janey said that she had felt a bit hesitant about giving her personal information, but the woman started crying while speaking about her situation, and Janey felt that she had to do something.
The school’s learning laboratory instructor, Brian, offered to work with the student to help develop insight on the issue. The learning lab had several relevant clinical scenarios. The learning objectives of the simulation activity for this student were as follows:
At the end of this lesson, the student will be able to
1. Describe appropriate nurse-patient boundaries and explain why the recent situation was a boundary crossing.
2. Recognize and describe situations in which she might feel tempted or pressured to behave in a way that crosses a professional boundary.
3. Apply strategies, such as therapeutic communication and planning of appropriate services, to appropriately help patients in difficult psychosocial situations.
To prepare for the simulation, Janey first met with the Brian. The objectives of the learning activity were described. Janey was assigned readings, including the ANA Code of Ethics, a chapter on “Professional Ethics and Boundaries” (DeWolf Bosek & Savage, 2007, pp. 77-79), and an article on professional boundaries (Sheets, 2000). On the day of the simulation, Janey first discussed the readings with Brian (CARNA, 2005). The instructor asked Janey what she learned from the readings and how she might respond differently. In working together, Janey was able to state specific verbal responses and actions such as responding to the patient with empathy, contacting social work to learn what services are available, and speaking with the patient’s nurse about considerations in discharge planning.
Next, the student completed a simulation with a teaching assistant (TA) playing the role of the patient. The scenario occurred in a simulation area that was set up as a hospital room to create the kind of conditions in which the student would face boundary challenges. The TA was in a gown, lying in bed with a simulated IV line. In this scenario, the TA played a young woman with cancer who was in an abusive relationship and seeking to leave the abuser. The scenario was similar, but not identical, to the situation that caused the student difficulty. As the TA cried and asked Janey, “what should I do?”, the student was able to practice the responses she had discussed with Brian such as:
Empathy: “It sounds like you’re in a really difficult situation. I’m sorry that things are so hard for you right now.”
Appropriate resources: “I know that there are resources for women in your situation. I’m going to speak with social work to see what is available for you.”
The student still used too much self disclosure (“My sister was in a similar relationship. It was hard for her to get out, but she’s doing really well now.”)
Janey, Brian, and the TA debriefed after the scenario. The student expressed that she felt much more prepared by having some rehearsed responses. The TA reflected that she felt reassured and valued by Janey. Janey recognized on her own that she had overstepped with the statement about her sister. With Brian’s guidance, she reflected on reasons for this (i.e., the need to provide reassurance to the point that the patient would stop crying). She left the scenario feeling more equipped to respond to boundary challenges and with awareness of situations in which she might be tempted to cross a boundary.
Implementing in a Group Setting
Janey’s scenario provides an example of a remedial simulation in which a boundary violation has already occurred. This approach could help get students back on the right track and develop confidence in dealing with difficult situations. However, simulation also could be used in a group setting to train students how to recognize and respond to boundary challenges (Schwartz, 2009). For instance, students might prepare for a simulation with readings and reflection as Janey did. They could brainstorm responses in small groups. They might participate in a simulation where one student acts as the nurse while the others observe, then debrief as a group what went well and what could have been done differently. Having different students address the same simulated situation would be a good way for students to learn responses other than those at which they might arrive on their own. Having the group practice on different scenarios could also be useful in having students apply similar skills across differing situations.
To summarize, it is important to offer students guidance on how to avoid blurring and crossing appropriate nurse-patient boundaries. As with any skill, protecting professional boundaries can be learned and practiced. Simulation is an ideal way to help student perform such practice and reflect on their own vulnerabilities and strengths.
References
American Nurses Association (ANA). (2001). Code of ethics for nurses. Retrieved April 30, 2012 from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf
College and Association of Registered Nurses of Alberta (CARNA). (2005). Professional boundaries: a discussion guide and teaching tool. Edmonton: CARNA.
DeWolf Bosek, M.S. and Savage, T. A. (2007). The ethical component of nursing. Philadelphia: Lippincott.
Greene, J. D., Morelli, S. A., Lowenberg, K., Nystrom, L. E, and Cohen, J. D. (2008). Cognitive load selectively interferes with utilitarian moral judgment. Cognition, 107(3), 1144-1154.
Schwartz, B. (2009). An innovative approach to teaching ethics and professionalism. Journal of the Canadian Dental Association, 75(5), 338-340.
Sheets, V. R. (2000). Staying in the lines: teach nurses how to maintain professional boundaries, recognize potential problems, and make better care decisions. Nursing Management, 31(8), 28-30, 32-34.
van Merrienboer, J.J.G., Sweller, J.(2005). Cognitve load theory and complex learning; Recent developments and future directions. Educational Psychology Review, 17(2), 147-177.
Updated on April 30th, 2012 at 10:09 am
For those of you who use the Jeffries/NLN Simulation framework in your simulation studies…
The Jeffries/NLN Simulation Framework has been in used for the past ten years as a framework for innumerable studies. A study group won National League for Nursing funding in 2011, to do a retrospective analysis of the framework , evaluating all the research completed using the framework to date and to determine if the framework has developed sufficiently to describe it as a theory, with some potentially testable hypotheses. The work group will report out at the International Nursing Association of Clinical Simulation and Learning (INACSL) conference in San Antonio, next June. In the meantime, they have established a website where you can view the work to date and comment- see http://nln-jsf.org/experts.
Updated on April 30th, 2012 at 10:11 am
In Autumn 2011, I used a new teaching approach with my first-year BSN Health Assessment students. The approach merged simulation with peer teaching. Below, I describe the steps that I used, followed by “lessons learned.”
Students attend lecture as a large group (about 65 students) and attend lab in small groups (about 12 students). To start the exercise, students completed group work in lecture to become the “expert” on an assigned case study. The cases represented various health issues and diverse populations. After a lecture presentation and demonstration of a system or regional examination by the instructor, students gathered in their assigned lab groups and wrote expected subjective and objective findings related to the system/region along with relevant nursing diagnoses. My co-teacher and I circulated among the groups to provide facilitation, particularly to make sure the more reserved or shy students were engaged.
After mid-term, students began to work on planning the actual simulation scenario. Lab sections were subdivided into 4-5 students. Students were instructed that they would participate in two simulations: one as Facilitator, one as Learner. Facilitators’ roles were assigned in advance and included (1) giving shift report to the learners to start the scenario, (2) playing the role of the patient (either acting or providing the voice for the simulator), (3) playing the role of a friend/family member, and (4) leading the debriefing. The Learners’ roles were assigned day of the simulation so all students would arrive prepared to play an active role in the simulation. Two learners played the role of the nurse and were expected to assess vital signs and perform inpatient shift reassessment. The rest of the learners were active observers and were given a checklist to keep them interested as they watched the simulation.
To prepare for the simulation, students they were given a template for giving report using the SBAR format (Situation, Background, Assessment, Recommendation – read more at the Institute for Healthcare Improvement Website). The group members worked together to fill out the report form. In formulating a head-to-toe report, students facilitated each others’ review of the overall course content. Next, students were given a template for scripting their acting roles. The group decided together how the roles would be played. They were given the following questions:
For the patient role
- What is the patient’s present mood? Level of consciousness?
- How will the patient interact (friendly and helpful, withdrawn, antagonistic, etc.)?
- What are cues you might give to the nurse about your status if asked? (e.g., hungry, in pain, want to be left alone, concerned about health, etc.).
For the friend/family role:
- What is the person’s present mood? LOC?
- How will the person interact with the nurses (friendly and helpful, withdrawn, antagonistic, etc.)?
- How will the person interact with the patient?
- What are cues you might give to the nurse about your status if asked? (e.g., curious about what’s going on, worried about care, etc.).
Students were given props to help the students get into the roles, and to help them have fun with the exercise. The student debriefers were given examples of questions to ask that they reviewed before the simulation day. They were given brief instruction in debriefing using the Plus/Delta method. Using this method, the debriefer first asks what went well, and then asks what the learner would change. Students were encouraged to add their own debriefing questions based on the scenario.
Finally we had the simulation day during the student labs. Students spent about 45 minutes in the simulation exercise and spent the rest of the lab session practicing physical examination. Of the 45 minutes, 15 minutes were spent in orientation, 15 minutes running the scenario, and 15 minutes debriefing. As the instructor, I oriented the students to the learning objectives and the overall purpose of the exercise. I cued each simulation to begin, and I provided the transition from the scenario to debriefing. I was present at debriefing, but interjected only when the inexperienced debriefer required assistance.
Overall, the simulations exercise was a success. Students were given the opportunity to provide anonymous feedback. On a scale of 1 (not useful) to 5 (very useful) students rated the exercise and average of 3.9 (range 2-5), and 87% of the students reported that they would recommend including the exercise in the course in the future. Many of the students reported that the simulation scenario and debriefing felt rushed. They would have liked more time. In addition, the students would have liked the simulation preparation to occur over fewer sessions (we used part of three class sessions in preparation). Students reported that a major benefit was feeling what it was like to perform with various distractions such as having the patient or family talking. The student debriefers were highly professional and respectful, and the others were willing to openly share both positive feedback and suggestions for improvement.
Based on this experience, I plan to include this exercise in next years’ Health Assessment course. The simulation preparation will take place in one session that immediately precedes the simulation day. In addition, I will have two lab days designated for simulation so that each group can have more time and feel less rushed. Finally, some of the cases did not translate well to simulation, and it was quite difficult to stage six different simulations in a limited lab space. I plan to use more case studies to illustrate examples in lecture, but reduce the number of case studies used for simulation to three.
Simulation is an active learning strategy, but as with lecture, it can be used in a prescriptive manner in which it is controlled by the instructor, or a collaborative manner engaging the learners in their own instruction. Our experience engaging students in peer-teaching using simulation was highly successful. I would encourage instructors not only to try our model, but also to be creative about other ways to engage your own unique student groups. And if you find something good, remember to pass it on!
Updated on April 30th, 2012 at 10:12 am
Recreating abnormal physical findings can be a fun and frustrating step in adding fidelity to a simulation. Mixing up blood and urine—no problem. Frustration arose when a heart failure scenario required pitting edema of the lower extremities. Manikins just don’t have a feature for the soft and spongy swelling associated with heart failure.
My “Ah-hah” moment happened when I purchased a memory foam pillow and noticed that if you pressed in with your hand the impression lingered and then recovered—exactly what happens when a patient is assessed for edema. I then set out to find a way to use memory foam on a manikin to look and feel like edema.
An internet search resulted in a foam cutting business who also worked with memory foam. To my surprise, there sold scraps of 1” blue memory foam for $1.00 and would cut it in half to make ½” foam pieces for no charge. Memory foam can also be purchased by the yard. An additional purchase, was a package of plastic “foot/ankle” models from a dollar store on which to practice.
Women’s knee-hi hose had been used in the past for safely covering the lower extremity of a manikin, so this was an obvious solution to the problem of how to hold the foam in place on the slippery foot and ankle. Not that easy. The foam slipped around on the plastic and the hose could not be slipped over the foam easily or at all. Gluing down the foam was out of the question. Also, the blue color looked creepy under the flesh-colored hose.  EdemaBlog_1
The challenges then were: 1) conceal the blue color without sacrificing the ability to leave an impression in the foam, 2) secure the foam so a cover such as the knee-hi hose could be applied and 3) solutions to 1 & 2 that do no harm to the manikin’s skin and appears as close to real skin as possible.
To conceal the blue color, tape or fabric would interfere with leaving the impression of “pitting edema”. In my search for tape, the answer came in a roll of 3M 2” tan Cobanã wrap. It had two features that were perfect—self-adherent and elastic. Now the blue memory foam could be covered, the wrap adhered to the foam to hold it in place and it was compressible.
A knee-hi hose in a color near the manikin’s “skin” color was chosen. Cutting off the toe and top band and sealing the edges with clear nail polish is optional. The hose was slipped over the foam- Cobanã covered foot and ankle. This could also be applied safely to a standardized patient.
Thicker memory foam can also be used in the female abdomen to mimic a fundus. Secure the foam over something more rigid, for example, a folded washcloth and insert under the abdominal wall. The thicker the foam, the more pregnant or boggy the fundus. EdemaBlog_2
Updated on April 30th, 2012 at 10:13 am
If you are like most computer users, you are likely drowning in usernames and passwords. Quite likely, you have passwords written down on scraps of paper, in spread sheets, and on sticky notes under your keyboard and in desk drawers. Maybe you have passwords that you know are weak and passwords that you haven’t changed in years. Sure – lots of web browsers offer to ‘remember’ passwords but is this a really good idea?
So what can you do? A couple years ago a co-worker, who is pretty heavily involved with web-server security and open source products, recommended a password storage solution called ‘Password Safe.’ Designed by an expert cryptographer, it stores all your passwords in a local file with robust encryption. It is an open source software project with licensing fees. I used it for almost two years and really liked it. I was careful to keep my encrypted file on the network drive at work so that it would be regularly backed up.
But time goes by and new products come out. While I liked ‘Password Safe’, I found it a little clunky and also difficult to use when I needed to work off two different computers which I usually do (my work computer and my laptop). Enter my friend again and a new recommendation: https://lastpass.com
I’d heard of websites that would store all of your passwords for you and was dubious, I didn’t like the idea of these sites having access to my goods. But, after reading more about Last Pass, I was convinced pretty quickly. It encrypts all of your passwords on your local machine and then transfers them via an encrypted SSL connection; the company only sees gibberish if they look inside of their database. You can access your ‘vault’ with a master password or passphrase which then un-encrypts all of your passwords. Lose your master password and you are toast, the company cannot help you.
If you install the browser plug-in (highly recommended!), Last Pass will recognize when you are visiting a site that is saved in your ‘vault’ and it will auto-log you in. When you are creating an account on a new site it will ask you if you want to ‘save the site’ to your vault and will even offer to auto-generate a strong password for you. Some additional features that I like:
- Imports usernames and passwords from a variety of other tools including passsafe.
- Exports all of your usernames and passwords if you want a local copy as a CSV file.
- Allows you to create a disposable, one-time use, master passwords to use on public terminals
- You can build profiles to speed up filling out web forms (no more entering your address over and over)
- Add secure notes inside of your vault.
- Get a pop-up virtual keyboard to enter your master password if you are working from a public terminal and worried about keyboard loggers etc.
- Create groups to organize your sites within your vault.
- Share specific usernames and passwords with other Last Pass users without them actually seeing the passwords. I’ve never done this but can think of some situations when it might be useful.
To be sure, it is not a perfect application. It has some rough edges. The vault looks much different when accessed via the website home page versus from the browser plug-in. With the latter, I can’t figure out how to manually add a new site to my vault. Fortunately, I rarely need to do this as it automatically adds new accounts. And sometimes sites end up duplicated in your vault because many sites have multiple log-in points with different urls. You can have the browser plug-in keep you logged in with your master password for a very long time. This can be dangerous if someone else gets onto your computer. But to mitigate against this – you can specify that highly sensitive sites in your vault will always prompt you to enter the password. There are many features that I have not yet explored and probably never will. But, bottom line, I’ve found it to be a real life-saver and far safer than my old practices which embarrassingly required a large supply of sticky notes!
And, if you don’t trust me, here is a review by an editor at CNET who also happens to be named ‘Seth’; his review says Last Pass is ‘an essential add-on for modern Web browsing.’ The review has some really great video at http://download.cnet.com/LastPass-Password-Manager/3000-18501_4-10889725.html
I couldn’t have said it better myself, though I tried!
Updated on April 30th, 2012 at 10:14 am
For nursing faculty, seeking the holy grail of simulation makes a difference in clinical performance (Kirkpatrick Level 3 evaluation). Meyer, Connors, Hou, and Gajewski (2011) demonstrated better performance in clinical after two weeks of simulation substituted for clinical, compared to groups without the simulation experience. This group devised a fairly simple but ingenious study design (see the article as it is much clearer with a visual): clinical faculty, employed by the hospital, were blinded to which students had been in simulation. All students in a clinical group were scored by their faculty every two weeks. Those with simulation first were scored consistently better than students who had not been in simulation.
Simulations were designed to cover things most frequently required of nurses in pediatrics, and were designed to move from simple to complex—with increasing complexity over the two weeks of simulations.
A simple evaluation tool with good reliability and validity, which evaluated performance, communication, clinical judgment, therapeutic skills, interprofessional communication, and documentation, was used biweekly by the clinical faculty to evaluate student performance. As clinical faculty, we are very aware of how little time we get to spend with any one student to form an opinion about ability and judgment. We know that our mental snapshots and words for the evaluation forms come from flitting images in the hallways, short conversations, skill observations at the bedside…frequently for 8–10 students spread out over the clinical rotation. However, in this study, students performed clinical skills significantly better after simulation. This is important in itself, as Ironside and McNelis (2010) found that clinical faculty spend almost 70% of their time observing students performing skills in clinical. Meyer et al. reported that these students did not perform better in clinical judgment. However, it is rare that students are allowed to make significant clinical judgments at the clinical site. The authors suggested that a more specific clinical judgment tool might have changed those scores. But that is for another study. This is a study deserving of replication.
References
Ironside, P.M., McNelis, A.M. (2010). Clinical education in prelicensure nursing programs: Results from an NLN National Survey 2009. National League for Nursing, New York.
Meyer, M.N., Connors, H., Hou, Q., Gajewski, B. (2011). The effect of simulation on clinical performance. Simulation in Healthcare, 6, 269–277.
Updated on April 30th, 2012 at 10:14 am
There was a very interesting series of three articles in the February 2011 edition of Simulation in Healthcare, on the use of the term non-technical skills (NTS), especially from a nursing perspective. Of great interest to me, was the fact that none of the three authors cited the REAL origin of this term. Michel Foucaut, a French philosopher, I argue, nailed the history of the (then non-existent term) NTS, with his descriptions of the “medical gaze” and the Panopticon. But more of that after a brief review of each of the three articles.
Debra Nestel argues that NTS means not relating to or valuing highly something not directly involved with science or technology. Communicating well with a patient or team members is not valued highly- hence the term NTS…technical skills being much more highly valued by western society. She prefers the term human factors.
Ronnie Glavin gives us the history of the term NTS, from the aviation industry and decries its mandatory measurement now by accrediting agencies. He includes a wonderful quote which is very telling- something about education is not teaching what on already knows but teaching you to behave as you would not behave. I guess his argument is, in the context of medicine that this means professionalism decreases humanity. He is the only one of the three authors who honestly alludes to the power hierarchy in, at least, US medicine.
David Gaba agrees that the term NTS is not precise and argues for a term more like behavioral performance skills and couches this term in processes for efficiency, effectiveness, quality, safety and performance assessment. Some transmission of values is present. Interesting and written like an engineer might approach the topic.
But I think these authors all missed the boat and in the end, danced around the topic in a way that nursing does not. Nurses call non-technical skills or human factors something else, ie. “therapeutic use of self”. One uses one’s humanness, a therapeutic use of self, to manage a team, a patient, a family, an organization. I think (physicians) medicine in general used a therapeutic self, back in the old days, when they really did not have much else to offer a patient, but a hand to hold and a few comforting words. But as they stopped making home visits and brought a patient out of his or her own environment into a the strange hospital environment…then built around a central ward with a central station from which a nurse or physician could see everyone at once and control behavior in the new hospital environment, Foucault’s “Panopticon”… and the all seeing eye, the above it all, hierarchical “medical gaze” developed. The therapeutic use of self abruptly declined.
The rise of technology further denigrated the need for good communication skills and therapeutic use of self, by anyone on the health care team. Relationships with patients became reductionist, technology ever increasing the distance between patient and provider…as a labor and delivery nurse, I saw fetal monitors destroy a new generation of nurses ability to care for a laboring woman. Technology has allowed physicians to devolve their NTS to the point where we are now forced to deliberately teach them again, as “symbols of science are more prestigious than symbols of caring”…Kim Walker as cited in Sandelowski (2000). I would argue that the terms NTS and human factors dance around the issue of what we all know is missing in health “care” today, the care part. If we are so embarrassed and disconnected that we have to call therapeutic use of self something devoid of real humanness, like NTS or human factors, woe is us.
See The Birth of the Clinic and Discipline and Punishment: The Birth of the Prison by Michel Foucault.
See Devices & Desires: Gender, Technology, and American Nursing by Margarete Sandelowski.
Updated on April 25th, 2012 at 5:11 pm
“If only I could demonstrate this concept to my e-learning students!”  An example of a screen capture
“If only I could share this terrific graph with my students!”
“If only I could show the step-by-step use of the course web page!"
If these are your thoughts, you may find that a free screen capture tool will save the day! For example, you can easily capture a graphic to insert in a document or powerpoint. The following pie chart was copied and pasted here using a screen capture.
Schroeder, S. A. (2007). We Can Do Better — Improving the Health of the American People.
N Engl J Med, 357, 1221-1228.
A screen capture tool performs two functions. It will make a single image of your screen, and it will record your screen as you open links and move your cursor (this is a ‘screencast’). You may record your voice during the screen cast. For additional ideas and examples on using a screen capture or screen cast tool such as Jing in education see Jing: Screen capturing, screencasting.
Possible uses in health science education include the following.
Students may:
- Record a narrated historical health or personal journey using Google Maps or Earth.
- Use as a digital story telling tool.
- Create health education presentations and share them on public web sites.
- Create an academic preseantation.
- Use as a reflection tool to explore the steps in a research activity.
- Use to communicate their thinking or reasoning about a challenging case or research question.
Educators may:
- Develop tutorials.
- Demonstrate the course web page parts and links.
- Create presentations with powerpoint or other software.
- “Think aloud” to deliver a personal or group message to students.
- Add voice and photos to personalize the distance learning experience.
The Jing Learning Center contains a wealth of tutorials and tips.
Please share your use of screen capture and screen casting in education, and recommend your favorite screencapture or screen cast software in the comment section of this blog.
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