Setting Boundaries with Residents, Nursing Home Magazine, March 2004

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.