Setting Boundaries With Residents
by Eleanor Feldman Barbera, PhD
Becoming close to residents, but not too close, takes wisdom
“Can you do me this one small favor?” Estelle H. 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 P. 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 comes when we start taking 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 W.’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 her 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.
Boundary breaking also tends to make the residents feel
emotionally unsafe. If Annie can’t trust Ms. Turner to behave
in a professional manner in their day-to-day interactions, it
raises the concern that Ms. Turner can’t be trusted with
health issues either.
On the other hand, with clear boundaries, the
relationship between Ms. Turner and Annie could be a delight
and a therapeutic experience for both of them. For example,
if boundaries are in place, Ms. Turner will be careful not to
reveal things that are too personal when talking about her
problems. Rather than seeking marital advice, she might ask
Annie’s opinion about what type of food to make for visiting
guests. In this case, Ms. Turner is discussing something she
wouldn’t mind everyone in the nursing home knowing about.
Still, she is helping Annie see that she has knowledge to
pass down to the next generation.
Of course, Ms. Turner will have to deal with the
possibility that Annie will suggest a dish that she has no
intention of cooking, but that is a minor issue that could be
finessed fairly easily. (“Annie, I didn’t make the tuna
casserole, but I liked the idea of a one-dish meal and made
lasagna instead.”)
The “Special Child”
Sometimes resident-staff relationships become problematic
because of their exclusivity. Most nursing homes in which I
have worked have rows of residents lined up in the hallway
watching everything that’s going on. They know exactly who is
talking to whom and for how long. They know who is getting
special favors, and who is the favorite and on what shift.
Being in a nursing home can be a very regressive experience,
and this regression can extend to a sibling-like comparison
between residents.
This “sibling rivalry” can undermine the self-esteem of
the less preferred residents and cause jealousies and
conflicts. Edgar, for instance, wondered why the staff hated
him after he saw another resident get immediate attention
when he had been waiting for an hour. He interpreted the
staff’s immediate care of a more engaging resident as his
being personally rejected. Claudette spent many sessions
bitterly complaining about her roommate’s treatment of her.
“She thinks she’s so high and mighty because she’s the
nurses’ pet!” she said one day, after her roommate had pushed
her tray table into an unreachable corner.
Comparisons between residents are a natural part of
group living and sometimes reflect underlying psychological
issues, but often the residents are responding to real
discrepancies in treatment. These do not reflect
maliciousness on the part of the staff, but they can occur
when staff members are not conscious of the impact they are
having on favored residents and their peers.
These situations not only occur in one-to-one
relationships, but they can also reflect a lack of clarity in
administrative policies. For example, one nursing home did
not allow electric wheelchairs until Samantha, a charismatic
young quadriplegic woman, returned from an extended pass in a
sporty red motorized chair and was allowed to keep it. This
set off a chain reaction among residents of jealousies,
complaints of preferential treatment, and plots to get chairs
of their own. Samantha herself became the focus of attention,
and numerous therapy sessions for her and her peers were
spent putting out the fires of resentment.
This situation could have been easily handled by an
administrative statement notifying residents that electric
wheelchairs would now be permitted and under what conditions.
It would have changed the impression that Samantha got
something for which the others were going to have to fight,
and instead would have created excitement regarding new
possibilities.
“I’m Not Ms. Turner”
Preferential treatment of residents can sometimes lead to
problems among staff members, too. Using our earlier example,
if Ms. Turner extends special favors to Annie, Annie will
come to expect this as part of her care. When other staff
members work with Annie in Ms. Turner’s absence, Annie might
seem overly needy or demanding. Or Annie might refuse care if
Ms. Turner isn’t providing it. I have heard more than one
complaint that Ms. Turner was “ruining” Annie for the rest of
the team. It is one thing to have a good working relationship
with a resident; it is another to have such a special
relationship that other colleagues can’t fill in when
necessary.
It can be difficult to address these problems with Ms.
Turner because it might seem like she is “just being nice,”
but there is such a thing as being too nice. When a staff
person is overly invested in one particular resident, it is
time to consider what might be in it for the staff person.
For example, is Ms. Turner trying to relive her relationship
with her grandmother? Or perhaps her relationship with Annie
is gratifying Ms. Turner’s need to feel important or
special—a need which should be filled elsewhere. My general
rule is not to do anything for one resident that I wouldn’t
do for any of the residents. That keeps it very clean.
Show Me the Money
Money issues theoretically shouldn’t exist in the nursing
home setting, but they do, and they can have dramatic effects
on resident-staff relationships. Money problems generally
arise when staff members are doing favors for the residents.
Sometimes residents will tell me that they were so grateful
that a staff person got them some take-out food that they
bought the staff person dinner also. They consider this to be
a reasonable transaction. I consider this to be highway
robbery. Most of our residents have a monthly income of $50.
Buying even a $5 meal for someone is equivalent to spending
10% of their monthly salary.
Also, once a staff member has accepted money for a
favor, it brings up the possibility of other tasks for which
residents think they should be paying staff members. They
shouldn’t be, but consider the position of the patient with
$50 to her name, wondering whether she should give out
holiday gifts or birthday presents to three shifts of aides
and nurses on her unit.
Favors should be done out of the goodness of one’s
heart, with no strings attached. Residents should be clear
about this from the start. Occasionally a resident will
insist that a staff person take a tip for his or her
inconvenience. This is often because residents are trying to
remove the feeling of dependency, by turning a favor into a
transaction for which they have paid. One strategy for
handling this is to tell the resident, “We can’t take any
kind of payment, and we can’t do the favor if you insist on
tipping.”
Another strategy is for the nursing home to have a
volunteer whose job it is to run errands. My “fantasy nursing
home,” would have a full-time errand runner who takes care of
all the “little things” that need to be done.
It would also have an “Independence Cart” wheeled around
regularly, selling phone cards, stationery, pens, greeting
cards, stamps, eyeglass repair kits, personal care items,
etc. It would be a roving store that took requests, so that
the residents wouldn’t need to be so heavily dependent on
others.
I once worked in a nursing home that had a food cart
that was pushed from floor to floor for the purpose of
selling candy bars and other junk food. It was a dietary
disaster but a practical and financial success. Someone would
go to the discount store and buy bulk items to sell at
reasonable prices. The money made for this service went to
resident trips and activities. Residents and staff alike came
to anticipate the cart’s arrival. Residents even helped to
stock and staff it. This concept, taken in the right
direction, could make everyone’s lives a lot easier.
Perhaps you are not the staff member getting egg rolls
in return for a run to the Chinese restaurant, but you are
more like Ms. Skinner in the beginning of this article. She
is the person waiting for John P. to pay her back for the
cigarettes she bought him. I feel for Ms. Skinner because I
bought a pack or two of cigarettes myself when I first
started, and I’ve yet to see a penny.
I now have a rule that I never purchase something for someone
with the intention of getting paid back later. I have had too
many bad experiences. Not that the money was the issue,
because generally it was a small amount. The problem was that
it completely changed the dynamic of the relationship. All of
the sudden I went from being the helpful psychologist to
“that woman I owe money to.” My advice, if you’ve gotten
yourself stuck in the position in which a resident is acting
funny because he owes you money that you know you are never
going see again, despite continued promises, is to give a
retroactive gift. Tell the resident you decided you are going
to give him the item you purchased for him as a gift and you
don’t want the money back. It will repair the relationship.
And then ban yourself from fronting the money in the future.
I get the money first and give the resident a receipt for it,
such as “$5 for the purchase of hand cream.”
Pleasant relationships with the residents are one of the joys
of working in long term care. We all need to “check in” with
ourselves occasionally to make sure our interactions are in
balance. Are favors done out of kindness, rather than to
meet our own needs? Are we treating residents equally well?
Have we resolved any outstanding money problems? Maintaining
clear boundaries provides a strong foundation for healthy,
growing relationships with those in our care.