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Setting Boundaries With Residents

March 1, 2004
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Staff must walk a line in maintaining peaceful relations by Eleanor Feldman Barbera, PhD
Setting boundaries with residents

Becoming close to residents, but not too close, takes wisdom

BY ELEANOR FELDMAN BARBERA, PHD "Can you do me this one small favor?" Estelle asked, looking up at her aide imploringly. "Can you get me a birthday card to send to my granddaughter?" Ms. Skinner sighed, thinking of all the things she needed to get done that evening, then looked into those sad brown eyes and acquiesced. A few hours later, she found herself acquiescing again when John asked her to buy him some cigarettes. She was going to the store anyway, she reasoned. By the end of the day she was tired, and the errands took longer than she had expected.

The next morning she handed the residents their purchases, trying to hide her resentment at having gone out of her way. Estelle was so thrilled that Ms. Skinner found herself agreeing to take care of another task for her. John, on the other hand, barely acknowledged her efforts and said he didn't have the money to pay her for the cigarettes. "As soon as my check comes in, I'll give it to you, I promise," he said, unwrapping the cigarettes as he spoke. Ms. Skinner had a feeling she'd never see that money again.

Sound familiar? It's happened to me, too I must admit. Setting boundaries can be difficult under any circumstances, but it is especially challenging when we are faced with reasonable requests from people who are legitimately in need of help. The problem starts when we take on too many extra tasks and begin to feel resentful, taken advantage of, or burned out. Boundary setting is not just about granting or not granting favors; it is about establishing appropriate personal guidelines in our relationships with residents. A lack of boundaries can foment jealousies and discord among residents and between staff members, and, when taken to an extreme, can lead to disciplinary action or job jeopardy. In order to set appropriate boundaries, it is helpful to be aware of the dynamics underlying resident/staff relationships.

Balance of Power
While we strive to create warm interpersonal connections with our residents, the relationship between residents and staff is inherently unequal. No matter what position we hold at the nursing home, from porter to aide to medical director, we are in a position of power relative to the residents. It is somewhat akin to a parent-child relationship. Because there is no one else they can rely on to take care of their needs, residents are dependent upon us the way children are dependent upon their parents.

Certainly residents can move to a different floor or different nursing home, but the same power dynamic will exist there. The bottom line is that the residents need us for their most basic functioning, and they do not have the freedom to walk away from relationships with us. With this powerful role, we have certain responsibilities. We must be the monitors of the relationship boundaries.

Confidentially Speaking
Just as responsible parents maintain an adult sense of privacy about their own personal lives rather than confiding in their children, staff members should be careful about what they discuss with residents and the impact it might have upon them both.

For example, Ms. Turner is a nurse who likes to take her work breaks in Annie's sunny third-floor bedroom. Annie is an 86-year-old resident who maintained her apartment in the community until a fall limited her mobility. She initially was a short-term rehab patient but now is planning to spend the rest of her days at the nursing home. She is bright, compassionate, and has a good sense of humor. It is no wonder Ms. Turner likes to talk to her. Annie is patient and understanding of Ms. Turner's problems, and really seems to enjoy their conversations. She feels a little special, being the one in whom Ms. Turner confides.

If Ms. Turner is not clear about her boundaries, she might share her marital problems and solicit the wisdom of Annie's years. By doing so, Ms. Turner is putting a lot of pressure on Annie to help her, although Annie is in the nursing home for her own needs and problems. She is unlikely to feel she should withhold her advice, because she needs Ms. Turner to care for her and wants to be liked by her.

Annie might also feel anxious about giving the "right" advice and worried about the outcome should Ms. Turner follow her suggestions. It would be difficult for any resident to say, "Listen, Dear, I know you are upset, but I'm an old lady and I have my own troubles. Why don't you try talking to your clergy or a marriage counselor." In addition, Ms. Turner needs to be aware that, although she might feel that talking to Annie is a lot like talking to her long-deceased grandmother, Annie could be a gossip. Does Ms. Turner really want to take the chance that her marital problems might become known throughout the facility? What a challenge it would be to continue working peaceably with Annie if she revealed a confidence to Ms. Turner's colleagues.

Another possibility to consider is that if Ms. Turner breaks her boundaries with Annie, the balance of the relationship might be disrupted. Residents have occasionally told me that that they "had something" on a particular staff member. They knew that if they told the administration about a boundary infraction that they could get the staff member in trouble. The staff member knew it, too. Sometimes these residents used the situation to manipulate the staff member in question.