Professional Boundaries

In this article, I want to present a concept that should be well understood by all CNA’s. Here, we’re going to discuss what can happen when we become overly attached to a resident, or their family and the implications this has upon the facility.

One of the better changes for some LTC facilities is consistent staffing. However, this staffing model has created some unintended consequences.

CNA’s develop long term relationships with those we are charged to care for. We grow to love them and will do all the little “extras” for them. Usually this doesn’t present a problem for anyone. But there are times when our relationships become unhealthy- for us, for the resident, for the other residents we’re assigned to; to our peers and to the facility we work for.

Over Attachment
In nursing homes, CNA’s can become too attached to a certain resident, in different ways. The CNA will be very upset if they are not assigned to care for this resident, or, will use their relationship with this resident as an excuse for being exempted from floating to other units. The CNA might spend inordinate amounts of time with this resident, and therefore shortchange the others assigned to him/her. The aide will always cater to this residents’ every whim before all others. This resident will have more needs than all others as well- and these “needs” will increase as times moves along.

Sometimes, the resident develops a fondness for an aide that isn’t healthy. The resident becomes dependent upon the aide’s presence to be happy. He or she refuses to allow other aides to work with him/her. Residents have “bad” days when their favorite aide isn’t at work. I have seen residents who believe they are “in love” with their favorite aides, especially those with mild dementia. I’ve also seen aides who care for patients in short term rehab centers develop “crushes” on these patients. The age difference between patient and aide isn’t that far apart.

Other assigned residents are neglected. Often. Or, the needs of these residents are tended to by the CNA’s peers. This creates a problem for everyone. Resentment sets in and working relationships suffer.

Being Objective
A huge problem with this arrangement, as it’s often called, is when the aide loses his or her ability to be objective. This is a serious concern. We must be able to truthfully report the conditions of our residents. This includes, but isn’t limited to, the residents progress or decline in all areas: Ability to speak, bath, dress, feed self, walk- are all very important. The CNA who is too close to certain residents isn’t able to accurately describe the resident’s true abilities.

This effects the resident directly: A resident who cannot really dress herself can be assessed as being able to do so. This might end up in a care plan…and other aides who work with this poor resident will get frustrated at THEIR ability to motivate this resident. Families are told their loved one can still dress herself when in fact she cannot, and hasn’t been able to perform this task for awhile.

We have professional boundaries
CNA’s are considered to be the professionals in the care giver-patient relationship. A CNA is expected to maintain a therapeutic relationship and not anything else. We have the upper hand because of our knowledge and skills. We are responsible for the care we deliver. Within the ethical discussions on this subject, the care giver always has power over the patient. Many times these relationships are for the benefit of the care giver and not the patient.

When the care becomes intertwined with personal friendships and over-advocacy, it’s not healthy. What is OVER ADVOCACY? It’s when we demand residents be given care, therapies and attention they don’t truly need. This is often where over attachment to a resident’s family starts. This is another whole problem- and the legal implications are high.

Ask yourself these questions. And be honest. If you can answer more than two of these with a YES, then YOU are crossing the professional boundaries. And setting yourself up for a lot of trouble.

* Have you ever spent off-duty time with a patient/family?

* Do you keep secrets with patients/family?

* Do you become defensive when someone questions your interaction with a patient/family?

* Have you ever given gifts to or received them from a patient/family?

* Have you felt possessive of a patient/family, thinking that only you could provide the care the patient needs?

* Have you ever flirted with a patient?

* Have you chosen sides with a patient against his or her family and other staff?

If you find that you’re overly attached, how to manage that? It’s not easy. The first step is recognizing you have a problem. Then, its a matter of distancing yourself from the resident. For some aides this is best done gradually. For others, a total cut off is appropriate. Many times, when the bosses see these problems, they’ll assign the aide to another unit altogether, effectively ending the relationship. I don’t think this is a good way to do this.

A CNA can ask for a change with their assignment. Being open and honest about this will almost always result in getting the changes you seek. Part of being PROFESSIONAL means keeping staffing issues to yourself. The urge to tell the resident, or the family, a change has taken place might be very high. Its best to leave these discussions with the nurse. And, after the resident and/or their family is informed, THEY will prod the CNA for information. Again, professional boundaries must take precedent over individual staff needs.

A note about being attached to resident families.
It’s not as common as resident-CNA friendships. But its much more dangerous. And, many times these relationships are initiated by the CNA.

Often times:
A family will block out all others in the facility and depend upon the aide for all communication. The aide will be put into situations they are not trained and educated to handle. Every word the aide speaks will be heard and recalled. If the aide doesn’t have the right information, or misspeaks, a lot of trouble can arise, legally.

The aide will become a spy, for the family. CNA’s are privy to some information that is private and confidential. The levels of care for other residents is an example. When we have over bearing families seeking information from aides who are all to willing to share, it creates huge management problems. It sets the stage for a turbulent relationship between the FACILITY and the family.
Some aides like to think families have some super power over a facility. This is simply not true. Government regulation and oversight have “power”; as do legal standards.

Other aides will use the family in an effort to be assigned to the resident they want. From my experience, these residents are almost always the ones who are considered “easy to do”– and the aide is simply seeking a guarantee of being assigned to this resident. There has been some evidence of aides seeking permanent assignment to certain residents in hopes of getting some monetary award. These situations are always unethical. The aides involved in this should be terminated from employment and barred from working as aides ever again. They are opportunists.

No matter whether a CNA is overly attached to a resident or their family, it’s not usually healthy. Most times the only way to stop the problems associated with these relationships is to separate the aide and resident. Perhaps, consistent staffing would better serve all if the assignments changed every so often. A couple times a year and all aides would be required to change no matter what family requests are. We all want what is best for the residents. Sometimes though, in order to insure this is happening equally across the board, we have to make adjustments and changes.


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