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Workplace Boundaries

Use Them to Decrease Distraction and Increase Joy

You’re having a very busy day with many patients on the schedule. You’re documenting information regarding a patient you just interviewed. During your hectic day, a co-worker approaches you says, “I don’t think I will have time to finish these calls; could you call these patients?” This same co-worker has periodically asked you to complete tasks that they are responsible for in the workplace. Despite having a full plate of tasks, you agree to help your co-worker.

In the above workplace scenario, what just happened? You think you’re helping a co-worker, but this person is repeatedly asking you to do their work. What is happening is a violation of boundaries. Of course, filling in to help a co-worker is fine, but when it becomes habitual, then it’s an issue.

Editor’s Note: The following package deals with setting boundaries in the workplace, such as boundaries with colleagues, bosses and patients, and against noise and distractions. Boundary-setting is more important than ever, because modern medical settings are more stressful than perhaps ever before, with the exceptions of say, COVID, or times of war. We have limited control over the workplace, but the following articles focus on where improvements might be possible.

What is a Boundary?

A boundary is a limit defining you in relationship to someone or to something. Boundaries can be physical and tangible or emotional and intangible. For example, a physical boundary is a fence, which identifies spatial limitations. Physical boundaries are concrete and easily identifiable. However, emotional boundaries are much less clear, which can make them more challenging to establish and enforce.

A line in the sand is a clear physical boundary. When a person steps over that line, they have violated the boundary. This same analogy can be used in emotional boundaries as well. For example, if a co-worker makes an inappropriate comment, they have crossed a line.

Having effective boundaries will not distance you from others. The boundaries prevent conflict and bring people together because, generally speaking, everyone knows what acceptable behavior is. This article will help you establish boundaries while still maintaining excellent relationships with co-workers.

Causes of Boundary Violations

Emotional Baggage

Everyone enters the workplace with some baggage. When people walk into the workplace, they do not leave their baggage by the door. Baggage brought into the workplace can affect interactions with coworkers, potentially leading to significant issues with boundaries. Many factors come into play, including the style of communication each person experienced in their families. Some people come from family situations where nurturing relationships were seen and modeled. Unfortunately, other people come from situations where significant dysfunction was present, and those styles of behavior walk into the workplace. Some people don’t realize they are violating boundaries in their communication style because in their environment, such behavior was acceptable.

Presenteeism

This term means that employees are physically present, but due to physical or emotional issues, are distracted to the point of reduced productivity. While absenteeism means they are physically absent, presenteeism means they are physically present, but due to other issues they are unable to function effectively to complete work-related assignments.

Many of the causes of presenteeism are rooted in psychological issues. For that reason, the workplace needs to have tools to help struggling employees, including stress-management support and, when needed, employee assistance programs. The privacy and confidentiality of such programs must be fiercely guarded—from both other employees and management—or employees will not feel comfortable using them.

Presenteeism leads to weak interpersonal relationships. Combining emotional baggage and presenteeism can lead to workplace toxicity and exacerbate the ensuing boundary violations.

Types of Boundaries

Co-worker Boundaries

Everyone in the workplace has job responsibilities and duties. In the example above, an employee was violating a co-worker’s boundaries by continually asking them to do their work. However, boundaries may not be directly related to job responsibilities. For example, a co-worker who often uses crude language or tells inappropriate jokes is also violating boundaries. This employee is violating the boundaries of people who expect the workplace to be free of bawdy language and tasteless or insulting remarks.

Patient Boundaries

There are appropriate interactions with patients, and then there are behaviors that cross the line, such as talking to patients about personal issues. Of course, chatting with patients about pets or a new restaurant in town is acceptable, but talking to patients about an abusive boyfriend is not appropriate.

Setting Boundaries

The following will help with the mechanics of boundary setting.

Follow the ABC Rule

ABC = Always Be Courteous. A person can still be friendly while setting boundaries. For example, in my work as a keynote speaker and workshop leader, the person who introduces me sets boundaries regarding mobile phones, and they’re always pleasant about it.

They kindly advise the audiences to please put their phones on vibrate. There’s no need to yell at people about the volume of their phones.

Identify Your Limits

The first step in setting boundaries is determining your limits, which can be emotional, mental, physical or spiritual. You set limits by noticing what you can tolerate and accept, as well as what makes you feel uncomfortable and stressed. These feelings will help you clarify your limits. Your limits are personal and are likely to be different than the limits of other people.

In one of my many boundary-setting workshops, an attendee mentioned a co-worker who had a habit of eating her lunch in front of her computer. The problem is that she liked eating fish and some co-workers thought the smell of the food was bothersome. A co-worker politely mentioned to this person the fish issue. The fish-eating co-worker immediately apologized and mentioned having no idea of the food having a strong odor.

Overall, listen to your feelings; they will tell you if boundaries have been violated. There are certain feelings that often signal boundary violations, including feelings of discomfort, resentment or guilt. These feelings are symptoms of boundary violations.

Clarity

Workplace boundaries must be clearly outlined so people in the workplace know what behaviors are acceptable. Each team member understands what to do, how to do it, and when to do it. This creates an efficient workplace environment. Managers must define and enforce the boundaries.

Passive-Assertive-Aggressive Behavior

Passive Behavior

Passive people are submissive and sometimes have feelings of low self-esteem. They do not stand up for themselves and are often sometimes referred to as doormats, in that other people can step all over them. Since some passive people feel powerless, they may have weak or nonexistent boundaries. They focus on the needs of other people. Even if they’re really busy, if a co-worker asks them for help, they will relinquish their own responsibilities to do someone else’s work.

Aggressive Behavior

Aggressive people are sometimes arrogant and may have unrealistic feelings of self-importance. Some belittle others and attack those who don’t share their views. Some aggressive people are tyrannical and have poor boundaries, since all their attention is on themselves. They focus only on their needs. If a co-worker asks them for help, they may refuse and be unpleasant.

Assertive Behavior

Assertive people are confident and self-accepting. These people have clearly defined boundaries. They focus on meeting their needs and the needs of others in a harmonious fashion. If they’re very busy and a co-worker asks them for help, they will politely explain that they can’t help now but will give them options to help meet their needs, such as checking back later or suggesting another person who might be able to assist.

Assertive people are comfortable and confident with themselves and have well-defined boundaries. The ideal workplace scenario is to have as many assertive people as possible since these types of individuals create a friendly and productive workplace. See Table 1 for a summary of passive, assertive and aggressive behaviors.

Handling Boundary Violations

Language

I suggest using “I” language and avoiding “you” language. “You” language can sound threatening, while “I” language comes across as pleasant, yet firm. For example, let’s say you have been asked to do excessive work and you’re feeling overwhelmed. These are two possible responses:

  • “You” version: “You’re giving me too much work. You have to stop this!”
  • “I” version: “I’m feeling overwhelmed. Let’s talk about solutions to manage the workflow.”

The “I” language version focuses on the sender’s feelings and is not accusatory. The response also blends in a solution-oriented perspective.

I also suggest avoiding “why” language. For example, a co-worker has not been completing assigned tasks. You have been forced to cover for this person and you’re feeling frustrated. You have reached a point where you have to say something. These are two possible responses:

  • “Why” version: “Why aren’t you getting your work done?”
  • “What” version: “What’s going on that’s leading to your assignments not being done? I notice this has been happening more often. Let’s talk about the situation.”

The “what” version is more friendly. The response also blends in a solution-oriented perspective.

Get It in Writing

There should be clearly written guidelines for employee job-related tasks and guidelines for interpersonal behavior to avoid boundary violations. Having clearly written guidelines moves the conversation from subjective to objective.

Two-Way Street

If you want people to respect your boundaries, then you must respect their boundaries. Be conscious of what you are asking of others. Is it reasonable?

Balance

We want clearly defined boundaries, but we must also allow for some flexibility. Our boundaries may need to vary based on the situation.

Get People Back on Track

People sometimes get distracted and go on tangents and need help getting back to the task at hand. The details of your co-worker’s vacation may be fun, but excessive discussions can take away from job responsibilities, hence violating your boundaries of completing assignments. In this situation, it’s important to respond gracefully, such as by saying, “Your vacation sounded wonderful. I need to complete this documentation, but let’s chat at lunch and you could fill me in more.”

Boundaries with Patients

Healthcare professionals must use caution when talking to a patient about their personal lives. The patient’s role is not to be that of a counselor. Only share limited and general information about life outside the workplace. However, some information can be shared if there is a benefit to the patient, such as an encouraging statement. If you had the same medical issue and are doing well, that type of discussion is certainly acceptable.

The actions of patients trigger emotional reactions among professionals. These feelings include sadness, anger and protectiveness, among many other feelings. It is normal to feel such emotions, but caution must be used in how these feelings are expressed. Emotional reactions can interfere with boundaries, including becoming too attached to certain patients while ignoring others. Becoming aware of these emotional reactions is the first step to looking at how they affect working with patients.

Terms of Endearment. Using terms of endearment can initially appear to be a gentle and kind gesture but can create issues. Calling a patient “sweetie” or “honey” may appear to be comforting to that patient, but it may also suggest a more personal interest than intended. It might also suggest favoritism to other patients who are not called by those nicknames. Some patients may find such endearments offensive or patronizing.

It is a good practice to avoid using these terms, as doing so could blur the clarity of a professional’s role in the life of the patient.

Burnout. Caregivers must learn to care for themselves. Providing care to frail and vulnerable patients is deeply rewarding, and sometimes deeply draining. The kind of giving that leads to burnout tends to involve behaviors done outside of the boundaries of one’s job. Being aware of the boundaries of one’s role and striving to adhere to those boundaries helps protect the caregiver from the destructive impact of burnout.

Gifts and Favors. Giving gifts to a patient or receiving gifts from a patient can blur the line between a personal relationship and a professional one. Have written guidelines for employees to determine what is acceptable as a gift. The same rules apply to favors, such as staying after work hours to “do a favor” for a patient.

Secrets. Do not keep secrets with patients. Do not share personal secrets with a patient and ask them to keep it a secret. Do not agree to keep secrets patients tell you. Secrets are different from confidentiality. Confidential information is shared with a few other members of a team providing care to a patient. Personal secrets compromise role boundaries.

Putting It All Together

Boundary issues will always be a part of the workplace due to a variety of factors, such as the communication skills and personal histories people bring into the workplace. A healthcare environment is a therapeutic milieu. To keep the environment therapeutic, boundaries must be established and implemented.

Through the strategies discussed in this article, you can minimize boundary issues. When equipped with the right set of skills, you can set boundaries while simultaneously creating positive workplace relationships that will benefit both your co-workers and your patients.

Author

  • Edward is the founder and director of the Center for Healthcare Communication, a consulting firm helping healthcare professionals effectively communicate with patients and each other.

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Overstimulated at Work?

Boundaries to Protect Yourself

More and more people in today’s fast-paced working environment feel perpetually on edge: unable to focus, plagued by a nonstop stream of notifications, and exhausted before the day even ends. This is due in part to overstimulation, which, in the healthcare setting, can be worse than almost anywhere else.

Overstimulation is when the brain becomes overwhelmed by too much sensory, cognitive and emotional input—in other words, far more than it can efficiently process. Overstimulation may result in irritability, exhaustion, lowered productivity and, finally, burnout. The modern workplace, with its open-concept offices, constant digital communications, and the demand for employees to be “always on,” has become a prime contributor to this growing problem.

Overstimulation is different from stress. Overstimulation is the state one goes through after being put through excessive use of information or sensory input in a short period of time. This could include noise, bright light, constant meetings, or multitasking in the hyper-connected world. When overstimulated, the brain can’t filter distractions and is unable to focus on the processing of emotions or any meaningful work.

Overstimulation occurs when incoming information, intearctions and sensory experience combined outpaces the brain’s capacity to process. A 2023 study in The Journal of Neuroscience reported that sensory overload complaints had increased 40% from pre-pandemic levels; this may well be a shift exacerbated by a return to office spaces and a surge in digital communication.

The Modern Work Environment

We work a lot differently now than we did just 15 years ago, and many of the innovations in the modern workplace—well-intentioned to help people collaborate and work more efficiently—surely serve to increase overstimulation. Here’s how:

The Open-Office Dilemma

Open-concept offices were once lauded as the future of collaboration. In reality, they’re often a sensory minefield of conversation, ringing phones, clacking keyboards, and impromptu meetings—making it nearly impossible for workers to focus. In that way, they’re not all that different than your typical nurse’s station or surgery center office. Researchers at Harvard Business Review found that, due to noise and distraction, employees in open offices experience a staggering 15% loss in productivity.

The average worker gets 121 emails a day and countless messages, texts and notifications. And with the expectation of immediate response, employees are constantly switching between tasks, leading to cognitive fatigue. According to a study by the University of California at Irvine, it takes an average of 23 minutes to refocus after an interruption, making digital overload one of the biggest contributors to overstimulation in the workplace.

Back-to-Back Meetings and Multitasking

Most employees find themselves caught in a vicious circle of back-to-back meetings, leaving little or no time for deep work. The compulsion to multitask—doing emails while on calls or messaging during meetings—prevents full engagement and increases cognitive strain.

The “Always-On” Culture

With the introduction of remote and hybrid work, the line between personal and professional life has continued to blur; people may feel obligated to check emails after hours or respond to late-night messages, leaving little time for actual mental recovery.

What Employers Can Do to Reduce Overstimulation

Creating a healthier work environment isn’t just about reducing stress; it’s about rethinking how we structure work to minimize cognitive overload. Employers can make a difference by instituting changes that protect mental well-being while sustaining productivity.

1. Normalize Quiet Spaces and Flexible Work Zones

While collaboration is invaluable, employees also need spaces where they can work without interruptions. Quiet rooms, soundproof pods, and “focus hours” can help temper the sensory overload of open offices.

2. Rethink Communication Overload

Organizations should set norms around communication to limit unnecessary digital interruptions. Encouraging scheduled check-ins rather than constant instant messaging, and implementing email-free focus periods, can make a big difference.

3. Prioritize Meaningful Breaks

Brief, intentional breaks throughout the day—say, walking outside, meditating or simply looking away from screens— reset the brain and prevent overstimulation from building up.

4. Create Meeting-Free Time Blocks

Companies like Shopify and Asana have successfully introduced “meeting-free days,” allowing employees uninterrupted time for deep work. Limiting meetings to specific time blocks can give employees more control over their schedules.

5. Encourage Separation of Work and Personal Life

Employers should model healthy boundaries by not intruding on employees’ time outside of work. Simple things, such as discouraging after-hours emails and setting clear expectations around availability, can prevent the always-on mentality that contributes to overstimulation.

What Employees Can Do to Protect Themselves

While organizational change is crucial, employees can also take proactive steps to manage overstimulation in their daily routines. These tips include:

Identify your triggers. Notice where and when overstimulation usually occurs, such as a noisy office, constant email pings, or back-to-back meetings.

Set boundaries with your digital tools. Turn off nonessential notifications, batch and check emails, and set “do not disturb” on during your focus time.

Take a sensory break. This may be breathing exercises, time away from screens, or sometimes just closing one’s eyes for a few moments—anything to help the nervous system reboot.

Express need. People are different. If some of the factors that are overstimulating you can be improved, talk with your manager or anyone else who may be able to help.

The Future of Work Deserves Smarter Spaces

Overstimulation is a challenge that calls for meaningful steps toward healthier, more sustainable work environments. It means rethinking building layouts, digital communication habits, and workload expectations to create a space where employees don’t just survive the workday but thrive in it. Taking proactive steps to reduce overstimulation isn’t just about productivity; it’s about creating a culture where employees can bring their best selves to work without the constant burden of mental overload.

Healthcare practitioners have no shortage of stress, and the job has some degree of overstimulation built in. However, reasonable steps can be taken to reduce overstimulation, and the changes will benefit both practitioners and the patients they care for.

Author

  • Ryan is a mental-health advocate and serves as marketing and social media manager for Give an Hour, where Ryan employs storytelling and community engagement to foster connection and hope, providing mental-health resources for those in need.

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The Battle Against Workplace Noise

From drug-infusion pumps to heart-rate monitors to low-battery warnings to bed alarms firing off for routine body shifts, the number of alarms calling out to clinicians has skyrocketed in recent decades. Hospital audits have tallied hundreds of alarms per patient per day, most of them inconsequential or false. The resulting “alarm fatigue” not only contributes to clinician burnout but can degrade patient care, according to the American Association of Critical Care Nurses.

It’s a vicious cycle of noise, as each new alarm must get itself noticed above the prevailing din, and one of the big topics I cover in my book “Clamor: How Noise Took Over the World— And How We Can Take It Back” (Norton, May 2025). I zero in on the problem of signal overload and potential fixes in hospitals and elsewhere in the chapter, “All the Machines That All Go Beep.”

The chapter explores alarm management, technology solutions and quiet times. It also argues for paying closer attention to the sounds themselves, to make them more helpful and less distracting, which is part of the story (excerpted below).

Fighting Sonic Inertia

The battle against alarm fatigue is not simply about volume control but also about revamping hospital soundscapes to better support clinicians and patients. Momentum for this larger cause continues to build on multiple fronts.

Among those working to extricate hospitals from the noisy trap of their own making is Yoko Sen, a sound designer and composer of breathy ambient electronic music in New York City. About a decade ago, after an extended hospital stay, she co-founded Sen Sound with her husband. Through countless interviews and workshops with patients, clinicians and medical-device makers, Sen and her team encourage people to think expansively beyond the beeps, not only focusing on the hospital noises they want to escape but also considering how to create a better soundscape for healing.

During Sen’s hospitalization, she lay surrounded by machines beeping with unflagging urgency, and she thought about a neuroscience study she’d read, which suggested that hearing is the last sense to go before we die. Would this piercing chorus of beeps be her final sendoff? It seemed so tragic. At one point, an alert on her bedside monitor sounded so shrill and persistent that her husband flagged down a nurse for help.

“Oh, don’t worry,” the nurse reassured him. “That thing just beeps.”

Telling this story, Sen laughs at the notion of a machine that “just beeps,” without meaning or apparent purpose beyond sounding its unceasing electronic yawp. But the vignette also captures

the neglect of the wider soundscape that lies at the heart of alarm overload. Its cacophony is a result of the decades during which hospitals accumulated sound-emitting technologies with little regard to the mounting cognitive burden they might place on staff and patients. In 2018, for example, a lead product developer at Philips, a prominent medical device company, contacted Sen after watching a talk she gave and invited her to work with his team. He admitted that his company had largely ignored the alarm sounds their patient monitors made, despite devoting decades of engineering and countless dollars to research and development of the machines’ other aspects. Eventually, he traced the current alarm sounds to a cassette tape dating from 1981.

This is an example of “sonic inertia,” and it wasn’t surprising to Sen. Constant beeps might keep patients awake and anxious, and they might stress out busy nurses and doctors, but as long as they successfully snagged clinicians’ attention, they worked, and the sounds they made were left alone.

Sen’s first challenge, therefore, was to raise expectations of alarms beyond basic functionality.

Collaborating closely with the Philips product-design team, she played the company’s then-current alarm sounds to gatherings of doctors and nurses and asked, “If the patient monitor was a person, who would it be to you, based on these sounds?”

“A drill sergeant,” somebody said. Others suggested a dictator, an ignored boss, or a petulant toddler.

When asked what they might prefer, the clinicians said they wanted the monitor to sound more like a coach, a friend, or some other helpful and supportive person.

“I wish it to be a colleague,” one doctor ventured, “with the same interests as myself: to do what’s best for the patient.”

The next step was a series of virtual workshops to solicit broader thoughts on hospital alarms from both clinicians and laypeople in a dozen countries. The project team dissected the transcripts of these sessions, clustered common themes, and ultimately distilled eight criteria for a successful alarm. Half of them related to “functionality,” such as being simple to learn and locate in space, easy to distinguish amid background noise, and quick to stimulate a response. The other half were measures related to “sensibility,” including how startling, aggravating, fatiguing or distracting the current sounds were.

With these criteria as a guide, Sen Sound and Philips’s product designers started reworking the sounds for low-, medium- and high-priority alarms. Clinicians had said they wanted the low- and medium-priority alarms, which they heard most often, to be less aggressive, so the team slowed the pacing of the beeps and made them softer and “rounder,” more like chimes with lingering notes. Medium-priority alarms were distinguished from low-priority ones by making them a bit more percussive and higher pitched, “like a gentle tap on the shoulder.”

High-priority alarms kept the original pacing of beeps, but the timbre was tweaked to make it less shrill and harsh—clinicians said they wanted to be “warned without being jolted.”

The project team then gathered feedback via two rounds of online surveys embedded with sounds—first they tested a handful of alternative alarms against each other and then pitted the winning alternatives for low-priority, medium-priority, and high-priority alerts against the originals. They asked listeners to give their preferences and to rate the alarms on the eight criteria.

This led to a surprising discovery. Everybody had expected significant tradeoffs between functionality and sensibility. They assumed that the acoustic qualities that grab attention and prompt immediate action would be opposite in nature to those that make sounds softer, gentler, warmer or smoother. Yet survey respondents mostly ranked their preferred sounds higher in both functionality and sensibility. And they preferred the new sounds to the originals overall. Philips adopted the redesigned sounds in 2023.

Solutions to hospital noise that have staying power will move beyond squashing problem sounds and proactively consider the bigger sonic picture: soundscapes matter for healing.

As a coda to Sen’s time in the hospital, she composed a “final sound” mix of music and spoken word (recordings from people she’d ask to describe the final sounds they’d want to hear in this life).

The voices talked about the sounds of water as a source of life, a transformative force, or the reassurance of breaking waves reaching out from a vast, unfathomable ocean. Others spoke about hearing the voices and laughter of loved ones, a chorus of birds that could kindle a “feeling of the morning when I’m waking up to something new,” or simply a rhythmic beat strong enough to “carry me to whatever’s next.”

For nearly five minutes, the piece echoed with final sonic wishes.

Not one beep could be heard among them.

Author

  • Chris is a science journalist and a former staff editor at The Atlantic and Mother Jones. He has written for numerous publications, including New Scientist, The Boston Globe, The Washington Post, and The San Diego Union-Tribune. He lives in Boston.

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TechTalk: Complex and Difficult

How to Clean Flexible Endoscopes Properly

Flexible endoscopes are complex devices that can be difficult to clean, therefore facility personnel responsible for overseeing reprocessing of flexible endoscopes should review reprocessing practices several times a year and ensure that processing personnel are adhering to the instructions of the endoscope, processing equipment, detergent and cleaning-supply manufacturers.

Cleaning in healthcare facilities is defined as “the removal, usually with detergent and water, of adherent clinical soil (e.g., blood, protein substances, and other debris) from the surfaces, crevices, serrations, joints, and lumens of instruments, devices, and equipment by a manual or mechanical process that prepares the items for safe handling and/or further decontamination” (ANSI/AAMI ST91:2021, p.4).

The Occupational Safety and Health Administration (OSHA) defines decontamination as “the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal” (29 CFR 1910.1030[b]).

The decontamination process involves two steps. The first and most important step is manual and/or automated cleaning. The second step is the application of a chemical disinfection or sterilization process. Although this sounds simple, each step has many components that must be performed correctly to ensure effective processing and the safety and health of employees, patients and the community.

Cleaning, followed by thorough rinsing, is the first—and probably the most important—step in the decontamination process. Without thorough cleaning, items may not be completely decontaminated. Patient deaths and/or infections have been traced back to flexible endoscopes that were inadequately cleaned. Meticulously performing all steps required for cleaning flexible endoscopes, components and accessories is essential to ensure they are safe for patient use.

Cleaning and rinsing remove rather than kill microorganisms. If contaminants such as blood, body fluids and tissue are left behind after cleaning, they can prevent disinfecting and sterilizing agents from contacting all surfaces of the endoscope and possibly create a breeding ground for microorganisms, making disinfection more difficult. And remember: Just because something looks clean doesn’t mean it is clean.

Personnel responsible for cleaning flexible endoscopes must wear appropriate personal protective equipment (PPE) to prevent exposure to contaminants such as blood, body fluids and tissue, as well as pathogenic and nonpathogenic organisms. Reprocessing technicians work in a wet environment and are also working with potentially hazardous chemicals such as detergents and disinfectants. The recommended PPE includes a Level 4 barrier gown, face shield or goggles, a fluid-resistant face mask, decontamination gloves, headcover and fluid-resistant shoe covers, per ANSI/AAMI ST91:2021.

Principles of Cleaning

Designated facility personnel must ensure that the manufacturer’s instructions for processing every type of endoscope used in the facility are available and followed. It is important for endoscope-processing technicians to understand that regardless of the facility or the items being reprocessed, the fundamental principles of cleaning remain the same. Certain general principles of cleaning apply to all items being processed. These principles include the following:

  • The cleaning solution must contact every surface of the endoscope or endoscope accessory.
  • There must be some type of physical action, such as friction, which enhances the cleaning process. Friction is the action of one surface or object rubbing against another. Friction is created by scrubbing, brushing and rinsing all surfaces of the endoscope during manual cleaning and by flushing and rinsing detergent through the lumens of the device.

The following nine factors have an impact on cleaning.

  1. Water quality
  2. Water temperature
  3. Cleaning activity of the detergents (also known as cleaning chemistry)
  4. Mechanical action
  5. Nature and design of the instruments or devices (e.g., simple or complex)
  6. Type of soil (e.g., blood versus fatty soil)
  7. Human factors/competence (e.g., training, complying with IFUs and using processing equipment correctly)
  8. Cleaning verification (checking and documenting the effectiveness of the cleaning process)
  9. Quality assurance (monitoring the cleaning process to ensure compliance with IFUs, facility policies and procedures, and applicable standards and guidelines)

When cleaning failures occur, one or more of these factors is involved.

It is important for all endoscope-processing team members to understand that disinfection and/or sterilization will not compensate for poor cleaning. The importance of performing adequate cleaning of flexible endoscopes cannot be overemphasized and is stressed in all professional guidelines and standards related to processing medical devices used for surgery and/or endoscopy. Further, the importance of obtaining and complying with the endoscope manufacturers’ IFU cannot be overstated.

The FDA had developed a guidance document, “Reprocessing Medical Devices in Health Care Settings: Validation Methods and Labeling Guidance for Industry and Food and Drug Administration Staff.” The purpose of this document was to guide medical-device manufacturers in creating and validating reprocessing instructions that, if followed, will ensure that their devices can be safely used for the purpose for which they were intended. Except for the specific regulatory or statutory requirements mentioned, this guidance document is not regulatory and is not legally enforceable; however, the IFU that manufacturers develop using this guidance document are recognized by the Joint Commission, AAMI, and other accreditation and professional organizations as providing a mechanism for the user to verify that the device can be safely reprocessed.

In addition to following manufacturers’ IFU, designated facility personnel must be able to verify the cleaning process recommended by a manufacturer. According to ANSI/AAMI ST58:2024, “Chemical Sterilization and High-Level Disinfection in Health Care Facilities (Annex N):” verification of a cleaning process consists of the following.

  1. Visual inspection combined with other verification methods to determine the cleaning of the external surfaces and the internal housing and channels of medical devices
  2. Testing the cleaning efficacy of cleaning equipment and
  3. Monitoring key cleaning parameters (such as the temperature)

Manufacturers provide such tests so the equipment can be tested efficiently without damaging the devices or necessitating recleaning of the device.

Quality Improvement

Designated facility personnel should ensure that each step in the cleaning process is fully verifiable through personnel training and through observation and that the process can be followed completely, accurately and without variation by all individuals who perform it; they must also provide process controls along with validation and verification methodologies that ensure adequate, consistent cleaning levels.

To define any facility process, designated facility personnel must develop written policies and procedures that identify the steps of the process. The policies and procedures should be based on published professional guidelines and should align with the validated processes described in the manufacturers’ IFU.

Designated facility personnel must also ensure that each employee completes an orientation program wherein the employee receives documented education and training about the tasks they will be performing at the facility and that the employee undergoes documented competency verification demonstrating their ability to perform the tasks correctly. After successfully completing their orientation, designated facility personnel should continue to provide education and training of employees as needed and should verify the competencies of each employee at least annually—or more frequently, as needed.

All personnel processing flexible and semi-rigid endoscopes should be certified in flexible-endoscope processing within two years of employment and maintain their certification throughout their employment (ANSI/AAMI ST-91, 2021).

The importance of implementing an effective cleaning process is underscored by accreditation surveyors who have been instructed to request that endoscopy technicians obtain the manufacturer’s IFU for a particular endoscope and demonstrate and/or describe the process that should be used to clean the device. This enables the surveyors to evaluate whether the employee is following the correct procedure to ensure the cleanliness and safety of the endoscope.

The manufacturer’s IFU for each device should include information about the recommended cleaning and/or disinfecting agents, cleaning implements, and cleaning methods that should be used, as well as instructions about how to disassemble the device for effective cleaning, if applicable.

If a manufacturer’s IFU are unclear, inadequate or contraindicated by best-practice recommendations from relevant professional organizations, designated facility personnel should contact the manufacturer for additional information and clarification.

Any information obtained from a phone call with a manufacturer’s representative or from a manufacturer’s sales representative should be followed by a written statement from the manufacturer confirming the information. It is not acceptable to rely on verbal instructions. All device manufacturers’ IFU should be readily available to processing personnel for reference. Failure to comply with the manufacturer’s IFU could void the manufacturer’s expressed or implied warranty and could result in high-level disinfection or sterilization failures. It is the responsibility of the processing professional to comply with the manufacturer’s IFU.

Summary

There are many more steps in the cleaning process and each one is important. It is up to the facility to ensure that staff are thoroughly trained and competent in the cleaning process. Routine observations and audits should be performed to ensure compliance with state policies and compliance with the device manufacturer’s current instructions for use (IFU). Some personnel who are responsible for cleaning do not recognize the importance of their job.

It is important to understand that the process of high-evel disinfection depends upon the disinfectant reaching ALL surfaces and channels of the device. If the device is not cleaned per the IFU, the disinfection process could be reduced or even nullified. That is simply not acceptable. Although not glamorous, your job is critical to good patient outcomes. The patient depends on you to do the right thing.

Author

  • Nancy Chobin, RN, AAS, ACSP, CSPM, CFER, is the president and CEO of Sterile Processing University, LLC, an online education and continuing education website.

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Taking Care of Each Other

Team Bonding Makes for Better Outcomes

Chelsea Hospital’s endoscopy team brings unique expertise to the table and a collaborative spirit that makes all the difference to their patients, according to Lindsey Quinn, RN, BNS, nurse coordinator.

“What truly sets our team apart is our unwavering commitment to excellence in patient care and our deep-rooted culture of support—for both our patients and one another,” Quinn said. “Despite being a relatively small team, we are mighty in our impact.”

The state-of-the-art facility in Chelsea, Michigan, is a joint venture between Trinity Health Michigan and U-M Health and features 16 pre-operative and post-anesthesia care-unit bays, two procedure rooms dedicated to pain management, and four fully equipped endoscopy suites. The staff includes 25 RNs, 12 per-diem RNs, two admin staffers, and seven surgical-care and instrument-care technicians.

In addition to outpatient services, the team also performs endoscopy and pain procedures for inpatients at Chelsea Hospital. The services include diagnostic and interventional procedures such as colonoscopies and esophagogastroduodenoscopies, dilations, banding, tattooing, cauterization, biopsies and snare polypectomies.

But at Chelsea, it isn’t just about the services. Quinn said, “Patient safety and well-being are at the heart of everything we do. We take great pride in the quality of care we provide, ensuring that every patient feels seen, heard, and supported throughout their experience with us.”

The core of that care is how the team takes care of each other.

“We are more than just colleagues,” Quinn said. “We are a work family. Many of us have walked through life’s highs and lows together, celebrating milestones and offering strength during difficult times.” This bond fosters a resilient, positive and supportive work environment that directly translates into better outcomes for the team’s patients.

Quinn’s colleague, Cara Olsen, RN, agreed. “Never have I worked with such a team that works so hard for the patient outcome and experience,” Olsen said. “As a team member you are loved the second you walk through the door. It’s a work family that is there for you in the good times and the bad. This is a rare find in work environments and what makes this team so great in my eyes.”

A few of the elements that make the team effective are the power of consistent communication, an ongoing mutual respect, and a shared commitment to both patient care and team well-being. “We believe that excellence in healthcare starts with a strong, connected team,” Olsen said.

Some best practices include:

Prioritizing patient safety and dignity in every interaction, no matter how routine the procedure may seem.

Maintaining open and honest communication through regular team meetings, daily huddles, and informal check-ins.

Fostering a culture of support and empathy, where team members feel safe to speak up, ask for help, and offer encouragement.

Celebrating wins—big and small—and recognizing each other’s contributions, which helps build morale and a sense of shared purpose.

Staying flexible and adaptable, especially during times of change or challenge, while always keeping patient care at the center of their focus.

Nicole Richardson, RN, has seen this firsthand. “Being in charge you see how much can change in a single day. Cases will be canceled, added, moved up in time slots, and moved locations. During these changes I get to see so many staff members step up, change assignments, and help others to get the job done.”

“Our philosophy is simple,” Quinn said. “When we take care of each other, we’re better equipped to take care of our patients. That mindset has helped us build a resilient, high-performing team that others can learn from.”

That’s not to say Chelsea Endoscopy doesn’t have its challenges. Quinn cited staffing shortages, increasing patient volumes and the far-reaching impacts of the COVID pandemic as some issues the team has had to sort through. “We’ve had to adapt quickly and work together to maintain the highest standards of patient care and safety,” she said.

The team has faced personal challenges, as well. Kimberly Hicks, RN, said part of the reason she loves her team members is because of the way they “come together when each other is navigating a difficult time in our lives. When it comes down to it, we are family and the support we give each other is beyond any other job I’ve ever had.

“What I love about our team is how we always pull together when things are crazy to provide the best care to our patients,” Hicks added. “Our patients would never know that it may be the worst day on the unit for staff because we mask it so well.”

Quinn agreed. “Through it all, we’ve remained a source of strength and support for one another,” she said. “Whether it’s covering shifts, offering a listening ear, or simply showing up with kindness, our team consistently demonstrates compassion not only for our patients, but for each other. These shared experiences have deepened our bond and reinforced our resilience. They’ve shaped us into a team that is not only highly skilled but also deeply empathetic and united by a genuine commitment to care—both within and beyond the walls of our department.”

This enthusiasm is shared by Denise Dembinski, RN, who said, “It’s good to work with people [who] are all committed to taking the best possible care of our patients. And also provide the best support for each other as we navigate life’s ups and downs.”

The team also celebrates achievements and milestones such as retirements, graduations and personal accomplishments— the things that make life rich and fulfilling. These celebrations often extend beyond work hours.

The team has gone on department outings such as renting a chauffeured bus to attend an event together, and they even went camping. In addition to social gatherings, the team holds monthly team meetings to stay connected professionally. These meetings provide a space to share updates, discuss improvements, and ensure everyone feels informed and valued. This ability to balance professionalism with genuine connection is a key part of what makes Chelsea’s work environment so positive and cohesive.

Quinn concluded, “Our exceptional teamwork, mutual respect and shared dedication make us not only effective but also proud of the work we do every day.”

Author

Under Threat

Medical Journals Receive Unprecedented Inquiries

Medical journals are no strangers to receiving letters. However, one letter that arrived recently at several journals was extremely unusual. The letter was from the United States Department of Justice.

“We were surprised,” said Dr. Eric Rubin, editor-in-chief of The New England Journal of Medicine, in an interview with National Public Radio (NPR). Rubin said the letter came from a U.S. attorney for the District of Columbia.

According to NPR, the letter asked about “misinformation, competing viewpoints and the influence of funders such as advertisers and the National Institutes of Health.” Such letters were also sent to JAMA, Obstetrics & Gynecology, CHEST, and possibly others. “The public has certain expectations, and you have certain responsibilities,” the letter added, with a request for response by May 2. The letter mentioned that the journal has tax-exempt status.

“It does feel like there’s a threatening tone to the letter, and it is trying to intimidate us,” Rubin told NPR. “We were concerned because there were questions that suggested that we may be biased in the research we report. We aren’t. We have a very rigorous review process. We use outside experts. We have internal editors who are experts in their fields as well. And we spend a lot of time choosing the right articles to publish and trying to get the message right. We think we’re an antidote for misinformation.”

I find it very concerning that government agencies would attempt to influence or intimidate medical publications through threatening correspondence. Such actions set a dangerous precedent and compromise the objective evaluation of healthcare interventions, treatments and policies. The staffs of medical journals ensure that research meets rigorous standards of methodology, peer review, and ethical conduct—there’s no need for government agencies to pollute this process.

The peer-review system exists precisely to insulate scientific evaluation from external pressures, whether political, commercial, or ideological. It’s not a perfect process, and there have been troubling incidents over time, but these instances are few and far between. We can trust the vast majority of research printed in reputable journals. In these publications, editors and reviewers assess research based on methodological rigor, statistical validity, and contribution to medical knowledge—not on whether findings align with any current political preferences. This independence has enabled medical science to advance treatments for cancer, develop vaccines that have saved millions of lives, and establish safety protocols that protect patients worldwide.

Government threats, such as the aforementioned letters, may chill the research environment itself. Scientists may become reluctant to pursue research or report findings that could attract government scrutiny. Yes, government agencies often have legitimate interest in understanding research findings, but feedback should be shared through appropriate channels such as public-comment periods, advisory committees, and transparent regulatory processes—not through an effort to intimidate publishers.

I hope the medical journals contacted by the DOJ will continue to resist pressure. I imagine they will. Patient lives, public health, and the integrity of American medical science all depend on maintaining the independence that has made American medical journals among the most respected and influential in the world. The leaders of such journals deserve our trust and support.

In far less controversial news (although somewhat related, since we’ve essentially been discussing boundaries), I hope you’ll enjoy our cover story about setting boundaries at work. This piece explores relationships with sometimes-difficult colleagues, bosses and patients. That topic is accompanied by articles that tackle setting boundaries with a different challenge: noise and distractions. This package begins on page 18. Lastly, you’ll see a familiar name in one of our editorial departments this issue. Our longtime Infection Prevention Now author Nancy Haberstich’s column is filling in for AfterCare’s Patricia Raymond while she’s on break. Nancy’s column is about antibiotic resistance. I wish this topic weren’t still relevant, but unfortunately, it is. You can find the column on page 28.

Author

  • Michelle has worked as a journalist, editor in chief and communications professional for more than 20 years with 12 years specializing in healthcare, including as editor in chief for the EndoNurse media brand. She’s the editor, ghost author and co-author of several books.

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Interviewing Patients

How to Get Answers Kindly and Quickly

A patient just walked in and gave you that laundry list of issues. You might become frustrated and think, “Where do I start with all the information?”

I’ve been having diarrhea for the past few days. I’m always in the bathroom. All the bathroom trips are so difficult because something is wrong with my one knee. I also feel queasy. While this is going on my heart is racing, maybe because of my nerves. I also have a lingering cough. Did I mention my jaw hurts?

This article will provide top strategies to help you gather and organize information in a timely fashion while still maintaining rapport and efficiency.

Rapport Before Report

Outside of emergency situations, first briefly focus on the emotional aspects of a patient’s experience and then move to the medical part. This action will assist you as prepare to gather patient information. This process puts the patient at ease, and they are more likely to be friendly and forthcoming with all information.

If the patient you are speaking with mentions their abdominal pain is making it hard for them to focus on their responsibilities in the workplace, it would seem logical to immediately ask about their symptoms. Stop. This person is having medical issues, but they are also describing strong emotions.

Instead of immediately asking about the symptoms, first use empathy. For example, you can say, “That must be very challenging.” The patient now knows you care about them and what to help. Now you are ready to ask about the medical issues. Unfortunately, many healthcare professionals bypass the emotional issues and go right to the medical situation. This leads the patient to think, “This person doesn’t care about me.”

The reason empathy works is because it leads to trust. Patients who feel trust in their healthcare team are more likely to be compliant—and hence have better outcomes. Let’s say two of your colleagues gave you advice: One colleague you trust, and the other you are not too sure about. Whose advice are you more likely to follow? Of course, the person you trust.

If a patient is asymptomatic, there are still ways to connect emotionally to enhance the interviewing process. In your electronic medical records, note the hobbies and interests of patients. In this way, when they walk in the door you can ask about their garden or favorite sports team. You put them in a good mood and that makes for a much more pleasant interview. My wife and I live with a houseful of pug dogs. When I walk into my dentist’s office, the first thing they say is, “How are the pugs?” I am immediately in a wonderful mood.

Opening Line

Asymptomatic patient: If the patient is not experiencing any issues, such as a person having a screening colonoscopy, then the opening line could be a simple, “Hello.” Outside of general updates regarding their health and medications, a friendly welcome works fine.

Symptomatic patient: First of all, do not say, “How are you?” to a symptomatic patient. This may seem odd and counterintuitive, but there is a reason to avoid this question. According to John Tongue, M.D., chair of the American Academy of Orthopedic Surgeons Communications Skills Project Team, “In the U.S., this is a greeting, not a question, that can put the ill or injured person in the awkward position of saying they are ‘fine,’ just before telling you their story or problem(s).”

Start with an open-ended statement or question, such as, “Tell me what is going on,” or “How can I help you today?” I used to ask patients, “What brought you here today?” but stopped after a patient responded by saying, “The bus.”

If you know a patient is coming in with a specific complaint, start with a general question anyway. This action is recommended in case the patient has a hidden agenda. The complaint they have on the phone may not be the real issue. After the patient states their chief complaint, do not yet ask for details until you ask these two words, “What else?” Asking these two important words will get all the issues out in open and avoid the dreaded, end-of-meeting, “Oh, by the way…” issues. You don’t want the patient to drop a bombshell just as you are about to walk out the door.

Nonverbal Factors

The patient: While asking the patient questions, look at their body language. Are you seeing any discrepancies? Does the patient say they do not feel stressed, but you notice their legs are trembling? Actions speak louder than words. Patients could say one thing, but the body movements tell the real story.

The professional: During the interview, look at the patient. Eye contact is a critical to tell the patient you are with them as they share their story. Based on the physical setup of the medical environment, sometimes eye contact may be challenging, such as when the patient is at a ninety-degree angle. However, on occasion, turn and look at the patient.

If possible, sit down so you are at the same level, eye to eye. Sitting sends the message, “I have time for you.” Patients perceive you are with them for longer periods of time when you sit. If you have one quick question for a patient, sitting is not necessary, but if the interview will be lengthier, have a seat.

Be Patient

Leana Wen, M.D., is the co-author of the book, “When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests.” The book is for patients on how to have more effective interactions with healthcare professionals. However, her strategy to help patients is something every healthcare professional must understand. Wen tells patients, “You can’t just give symptoms; you have to give your story.”

When interviewing patients, focus on their story, not individual symptoms. A series of disjointed symptoms may be hard to piece together, but a story in chronological order can solve the mystery.

Healthcare professionals are often so focused on symptoms, they lose sight of the story, or “the big picture.” We must allow patients time to speak without being interrupted so they have sufficient time to tell their story. The type of questioning seen below could be problematic:

Patient: “My belly hurts.”

Professional: “Is the pain worse on the right or left?” Patient: “The right, and—”

Professionals: “Is the pain worse when you sit or stand?”

When we constantly interrupt patients, we may miss the story and may miss the real medical issue. In addition, it’s simply rude. Instead, ask an open question and let them tell their story with an occasional “Go on,” or “Tell me more,” sprinkled in the conversation. Once you have heard the entire story, then you are ready to ask the specific details.

I am a firm believer in this story process because I was misdiagnosed for over a decade due to no one giving me the time to share my story. About 20 years ago, I began having sinus headaches. I visited my family doctor’s office and was told to try over-the-counter medications. The meds didn’t help, so I returned to the office. I was then told I had an infection and was put on antibiotics. After taking a course of antibiotics, I had no symptom relief.

Next, my family doctor referred to an allergist, who discovered I had an allergy to molds. We thought we found the answer to my problem. I was put on allergy shots. After two years, my headaches got worse. I stopped the allergy shots and for years spoke to different healthcare professionals.

My family doctor then suggested trying the allergy route again with a new allergist. The new allergist’s style of interviewing was dramatically different than everyone else I spoke with during my struggle to get answers. She said, “Tell me about your headaches,” and she let me talk with no interruptions except for an occasional, “Go on.”

The other professionals I saw would constantly interrupt with questions about my specific symptoms. While she let me talk, I revealed that when the headaches got bad, I would feel nauseated and sometimes vomit. After I was done telling my story, she stated, “No allergy testing will be done today. You don’t have sinus headaches, you have migraines.” I was misdiagnosed for years because no one gave me the chance to tell my story, as they were too busy focusing on individual symptoms. I wasn’t closed off to discussing the GI symptoms; I simply was never allowed to talk long enough to reveal them.

The best way to get to the story is ask an open question, stop talking, and start listening.

Too Many Issues, Not Enough Time

The example used at the beginning of this article (in which a patient has a large list of issues to discuss) must be handled in a thoughtful manner. We want to maintain an excellent patient experience but also manage all the medical issues. There is right way and wrong way to handle this situation. Below are examples of a harsh inappropriate response and a sensitive helpful response.

Ineffective response: “We don’t have time to discuss all those issues.” This response results in the patient feeling angry. This response doesn’t set the stage for a productive interview since we started in a negative manner.

Effective Response: “I wish we had time to discuss everything today. How about if we discuss these two issues: ______ and ______. We’ll schedule another appointment for the other issues. How does that sound to you?” This response is friendly and creates a wonderful experience for the patient. This response also highlights shared decision-making, since you asked the patient their thoughts on your suggested course of action.

Avoid “Why” Questions

Using the word “why” can often be seen as judgmental and should be avoided. This will make the question seem much harsher for the patient, rather than putting them at ease.

Think about the questions you heard growing up (at least, I heard them as a kid): “Why is your room so messy?” and “Why didn’t you eat your vegetables?” These questions are toxic because they come across as accusatory, and since the healthcare environment is a therapeutic milieu, we should create a comfortable place for patients.

Converting “why” questions to “what” questions creates a friendly feel to the interview. Here are examples:

“Why” question: “Why did you stop wearing your support stockings?”

“What” question: “What was happening that led you to stop wearing your su

pport stockings?”

“Why” question: “Why did you stop taking your medication?”

“What” question: “What could we do to get this medication back in your life?”

“Why” questions should also be avoided when talking to colleagues, family members and friends. These types of questions make everyone feel defensive.

Use “I” Language, Not “You” Language

Using the word “you” is verbally pointing your finger at the patient. During the interview, if the patient states they were not compliant or engaged in unhealthy activities, do not use “you” language. The example below will clarify the vast benefits of “I” language in these situations.

An example of a diabetic patient who admits to not being compliant with their diet.

“You” statement: “You have to watch your diet.”

“I” statement: “I want to help you. I want you to feel better. Let’s talk about your diet.”

The “you” example sounded harsh, while the “I” example sounded caring.

To enhance your interviewing skills even more, combine “you” language with “non-why” questions, and you’ve got a winning strategy.

Family Dynamics

Focusing on the patient, ignoring the family: I have observed thousands of healthcare professionals interacting with patients. In many cases, I have seen the professional walk in and immediately start speaking to the patient—but completely disregard the family members or friends in the room. This is a problem for many reasons.

First of all, you want to be sure the family members also have a good experience. In addition, the family members can add to the story as you ask questions. Yes, direct your questions to the patient, but also be sure to let family members know they can add to the discussion. Family members are your allies.

When it comes to focusing on the family but ignoring the patient, just because a person is older doesn’t mean they can’t answer questions. I recall many times when I would take my mother to a medical appointment, the healthcare professional would look at me and say, “How is she doing?” My mother wasn’t having any cognitive issues and would feel very frustrated that the questions were being directed at me. If the patient is cognitively aware, ask them the questions.

Summarize the Patient’s Story

After the patient has shared their story, briefly review the story to be sure you have all the facts in chronological order. This is a very important process. In this way, you can verify you have not missed any important details.

Smoothly flowing interviews help keep patients satisfied and safe. They also help professionals, too. By following the tips in this article, you’ll be more productive and feel less stressed.

Author

  • Edward is the founder and director of the Center for Healthcare Communication, a consulting firm helping healthcare professionals effectively communicate with patients and each other.

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Workplace Boundaries

by Bill Eikost
September 5, 2025
0

You’re having a very busy day with many patients on the schedule. You’re documenting information regarding a patient you just interviewed. During your hectic day, a co-worker approaches you says,...

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