# Situation: The nurse is a staff nurse on an inpatient psychiatric unit. The unit team of psychiatrist, nurses, psychologist, social worker and occupational therapist meets weekly to review care plans and to settle disagreements about unit routines. The team agreed that a client with borderline personality disorder may use the unit telephone twice a day. The nurse notices that a colleague has let the client make extra calls on three evenings. What is the BEST action by the nurse?

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> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: The nurse is a staff nurse on an inpatient psychiatric unit. The unit team of psychiatrist, nurses, psychologist, social worker and occupational therapist meets weekly to review care plans and to settle disagreements about unit routines.

The team agreed that a client with borderline personality disorder may use the unit telephone twice a day. The nurse notices that a colleague has let the client make extra calls on three evenings. What is the BEST action by the nurse?

## 보기

1. Tell the client that the colleague broke the unit's agreed rule
2. Talk privately with the colleague about keeping to the team plan **✔ 정답**
3. Allow extra calls on the nurse's own shifts so the client is treated equally
4. Report the colleague in writing to the chief nurse right away

**정답: 2**

## 해설

A colleague's departure from the team plan is first addressed directly and privately, using an assertive, respectful message that names the behavior and its effect on care. If the problem continues, the nurse reports it through channels. Consistency among all staff is essential for this client, so the nurse neither criticizes the colleague to the client nor joins the inconsistency.

## 심화 해설

The situation describes a conflict between individual staff behavior and an interdisciplinary team plan on an inpatient psychiatric unit. The client has borderline personality disorder (BPD), and the team agreed on a limit of two telephone calls per day. A colleague has allowed extra calls on three evenings. The nurse must choose the best first action.

Why the team plan matters for BPD

In BPD, emotional dysregulation and interpersonal instability are core features. Inpatient treatment relies on a therapeutic milieu in which all staff apply the same expectations and limits. When one staff member allows extra calls, the client experiences splitting—viewing staff as either all-good or all-bad—and may test boundaries with other team members. Consistency is not merely a preference; it is a treatment intervention. The team agreed on the limit precisely because predictable, uniform boundaries reduce the client's anxiety and limit testing behaviors [1][2].

A single staff member's deviation from the agreed plan undermines the entire treatment frame, not just one evening's phone use.

Why the first step is private, direct communication

The nurse's best action is to speak privately with the colleague. This follows the principle of addressing a practice issue at the lowest appropriate level before escalating. The message should be assertive and respectful: name the specific behavior (allowing extra calls on three evenings), state its effect (inconsistent limits for a client with BPD), and request adherence to the team plan.

Key point! The goal is not to punish the colleague but to restore consistency of care. Private conversation preserves the colleague's dignity and allows for clarification—perhaps the colleague was unaware of the agreement or misunderstood the rationale.

Why the other options are incorrect

| Option | Problem |
| --- | --- |
| 1. Tell the client that the colleague broke the rule | This criticizes a team member in front of the client, which feeds splitting and damages the client's trust in the team. It also places the client in the middle of a staff conflict. |
| 3. Allow extra calls on the nurse's own shifts | This joins the inconsistency. The nurse would be repeating the same error, reinforcing the client's belief that limits are negotiable depending on which staff member is present. |
| 4. Report the colleague in writing to the chief nurse right away | Escalation is premature. The first step is direct, private communication. Written reporting is reserved for situations where the behavior continues after direct discussion or involves immediate safety risk. |

Watch out! In BPD care, staff disagreement is a clinical issue, not just a personnel matter. The client will detect inconsistency and may use it to obtain privileges. Addressing the colleague privately protects both the treatment plan and the working relationship.

Therapeutic boundaries and team adherence

The Gunderson Residence model emphasizes that milieu-based care for personality pathology requires an integrated, consistent approach across all disciplines [2]. Staff must hold the same boundaries so that the environment itself becomes therapeutic. When one staff member deviates, the client's sense of predictability is disrupted, which can increase emotional dysregulation and acting-out behaviors [1].

Consistency among all staff is a core nursing intervention for BPD, not a bureaucratic rule. The nurse's role includes monitoring adherence to the team plan and addressing deviations through direct, respectful communication.

If the private conversation does not resolve the issue—if the colleague continues to allow extra calls—then the nurse would report through the appropriate chain of command. But the first action is always the direct, private, assertive message.References (research sources)

- [1]Borderline personality disorder: Challenges in an inpatient setting.Research articleChazhoor J, Younger J (2026) · DOI: 10.1177/10398562261486316

- [2]Integrative Residential Treatment of Co-Occurring Borderline and Narcissistic Personality Dysfunction: Perspectives from the Gunderson Residence.Research articleJacob KL, Unruh BT. (2026) · DOI: 10.1097/hrp.0000000000000475

## 임상 시나리오

Managing Staff Inconsistency in BPD CareRestoring the Therapeutic Milieu
For a client with Borderline Personality Disorder, consistent limit setting by all staff is a core treatment intervention. A deviation from the team plan can trigger splitting and boundary testing.

The first step is to address the colleague privately and directly. Use an assertive message that names the behavior and its effect on the client's care, such as allowing extra calls on 3 evenings.

CautionDo not criticize the colleague to the client or join the inconsistency by allowing extra calls. Escalate through formal channels only if the private discussion does not resolve the issue.

## 핵심 개념

- **Therapeutic Milieu** — A structured inpatient environment where all staff consistently apply rules and limits to promote emotional stability and reduce testing behaviors.
- **Splitting** — A defense mechanism common in BPD where the client views people or situations as all-good or all-bad, often leading to staff conflict.
- **Interdisciplinary Team Plan** — A collaborative care plan developed by professionals from different disciplines to ensure unified treatment goals and interventions.
- **Assertive Communication** — A respectful, direct style of addressing issues by naming the specific behavior and its impact without being aggressive or passive.
- **Limit Setting** — A therapeutic intervention that establishes clear, consistent boundaries to reduce anxiety and promote a sense of safety for the client.

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