Setting boundaries with residents: becoming close to residents, but not too close, takes wisdom.

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.

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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 with hold 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.

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 takeout 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 from 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 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, however, 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.

Eleanor Feldman Barbera, PhD, is a psychologist consulting in nursing homes. She is writing a book on her experiences in long-term care. For more information, phone [phone] or e-mail [e-mail]. To comment on this article, e-mail [e-mail]. For reprints, call [phone].

BY ELEANOR FELDMAN BARBERA, PHD