Monday, July 28, 2008

Attachment and Its (Dis)Contents

Over the course of the summer, I have been working several days a week at my former place of full-time employment while several of my colleagues take well-deserved vacations. As an agency that specializes in the care coordination and care management of the urban poor who live with chronic illness, it is by nature a challenging and potentially draining job. I was a living testament to the vicissitudes of the position, resigning in January of this year after eight years of hard labor. With chronic stress and stress-related illness, I knew that it was time to go (and that my departure was more than likely long overdue). Still, going back to my old office is like "Old Home Week" and my level of comfort there is still considerably high.

Seeing several patients on a regular basis (albeit temporarily), I noticed how easy it is to get emotionally attached again. After four weeks of regular visits to one disabled and chronically ill couple, I was already falling into patterns of the Nurse Care Manager: ongoing "in" jokes with my temporary patients; an increasing feeling of comfort with what was at first an uncomfortable and new home environment; positive mutual regard; and a sense that I could make an impact on these individuals' lives through small but thoughtful actions and kind, carefully chosen words.

Conversely, the down side of such closeness also begins to rear its head quite quickly as well: a sense of dependency from the patients towards me; a feeling like I could never do enough; a feeling that I now "owned" this patient's care and had to resolve everything or it would never get done. These are warning signs that I am still not ready for full-time work, for case management, for the responsibility and boundaries that are part and parcel of carrying a caseload.

As a per diem hospice nurse for a local visiting nurse agency, I am now finishing my orientation and will begin seeing patients as needed when my colleagues are on vacation or sick. Again, here is another opportunity to have intimate and personal contact with patients and their families, mitigated by the fact that I am "just a per diem nurse" and am not assuming responsibility for their care over the long term.

Attachment in my line of work is normal, expected, and healthy. Staying in one job for a long while (like I recently did for eight years) and managing the care of the same patients for that long a period of time can be quite challenging. Projection, transference, counter-transference and a host of functional and not-so-functional issues emerge. Yes, it is great fodder for personal development, emotional growth, and spiritual practice, but it is also rife with danger for those who, like me, can be challenged by the boundaries that must be clearly delineated in order for one to remain healthy in such a position.

Personally, I am still happy to not be managing anyone's case at this point in my career. As a per diem nurse, I show up, I do my job, I engage with patients as deeply and fully as the situation allows (and hospice certainly allows for such engagement), and at the end of the day, I go home and rest my head, free of the long-range planning and calculating that make case management so very exhausting.

I still feel emotional attachments to some of the patients that I managed for those eight long years. Working at my old office, I run into one or two here and there, or even schedule a visit when it's clinically appropriate to do so. However, I am happily disengaged from all of those nurse-patient relationships that drained me for so long, and my case manager hat gratefully rests on a dusty peg in a dark closet.

Attachment is lovely in clinical relationships, but at this point in my life, only short-term attachment holds an appeal. When a patient is in front of me, I am wholly there, present and accounted for. But when I go home to my personal sanctuary, I give thanks that there aren't still eighty people living in my head from dawn to dusk, clamoring for attention that I have no energy to bestow. I should count my blessings every day.
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