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Role Boundaries in the Long-Term Care Setting
by Tom Medlar, M.A., LMHC

Role Definition and Limits

Role: The function assumed or part played by a person or thing in a particular situation.

Boundary: A line that marks the limits of an area; a dividing line; a limit of a subject or a sphere of activity. (The New Oxford English Dictionary)

Each job title entails particular duties and responsibilities. Within each position there are routine tasks and activities and expectations. Individuals are specifically trained to perform the responsibilities of their role. And each role involves limits. Every worker is expected to limit herself or himself to the usual and customary activities involved in the fulfillment of their role.

Types and amounts of education, training, salary, supervision, clothing, scheduling, authority, and responsibility define roles. Different roles contribute to the functioning of the facility as a whole. An individual's performance of his or her role is observed and evaluated by residents and their family members, by peers, by supervisors and colleagues, by administrators, by citizens and organizations in the community in which one works, and by certifying or licensing boards, by State and Federal authorities, and by other regulatory agencies.

It is important that one consistently adhere to the established tasks and activities and expectations of one's role. It can be disruptive or even harmful to take actions outside of the limits or boundaries of one's role. Certain limits are obvious, such as restrictions against sexual contact with residents. But other actions can blur the essential line between staff and resident but be less apparent. This paper will discuss a variety of areas in which boundary blurring or boundary violations could occur. Hopefully, this discussion will shine some helpful light on these important but sometimes subtle issues.

As professional helpers we can contribute significantly to the well being of residents in the long-term care setting. But if we act in ways that violate the boundaries of our role we can cause potential harm to our residents, our employers, and ourselves. Professional care giving can be powerfully helpful or powerfully harmful. Electricity is a powerful force, but needs to be control and focused in order to perform helpfully. The rubber insulation around an electrical cord protects and directs the force of the electricity. If a cord is damaged or frayed the energy can be less effectively delivered, or could become a danger. Role boundaries provide a type of insulating and directing function. The results of our work will be more effective to the degree in which we adhere to the limits of our role. If we act outside of our role the powerful emotional forces involved in care giving can go awry and can cause harm.

Sharing Personal Information

"They're supposed to go around and take care of you and not take out their problems on you. And they do have a lot of problems, you know, some of them. They sometimes tell me their problems, and tell me not to tell anyone. I've got enough problems of my own. I don't think they should be telling so much of their problems." Quote from a Resident

Use caution when talking to a resident about your personal life. Do not share information because you need to talk, or to help you feel better. Only share limited and general information about your life outside of work. And only do so if you are thinking of a reason why it may be useful to the resident, such as a teaching example, or an encouragement.

Emotional Reactions

The actions of residents will trigger emotional reactions in staff persons. A resident's behavior can stir anger or pity, disgust or endearment, impatience or curiosity. It is normal that a worker might feel sadness, annoyance, fear, repulsion, attraction, protectiveness, hostility, bewilderment, or sympathy in reaction to a resident's behavior. It is normal to feel such emotions but it is not helpful to express or act on all of our emotional reactions.

Emotional reactions can interfere with the functioning of our role. One could become overly attached to certain residents, and create feelings of hurt or rejection for other residents under one's care. One could be overly fearful of or annoyed by some other residents and deprive them of the equal care they deserve. Our job is to act with an equal degree of energy, thoughtfulness, and commitment to each of the individuals under our care. Intense and unexamined emotional reactions can disrupt or distort one's role.

Too often we may react to a resident's behavior as bothersome and disruptive without looking thoughtfully at how it is reflecting that individual's problems and limitations. It requires skill to learn to view a resident's behavior as symptomatic, as reflective of underlying disorder. All staff can develop and refine this skill. This skill requires practice, as do all skills. It takes practice to see the emotions that are stirred in us by the actions of the resident(s). It takes practice to step aside from our immediate reactions so that we can see our feeling rather than be it. Then we can take notice of how we feel rather than simply feel it and act on it.

We need to practice this skill of stepping back, or stepping aside from our emotions. This does not mean ignoring or discounting our feelings; it means gaining a new point of view on them. It is similar to adjusting a telephoto or telescopic lens. Sometimes we want a very close and detailed look at something, and other times we need a more distant look so we can put the thing in perspective. Being able to delay our reaction and adjust our view allows us to respond with more thought and more choices.

It is a mental and emotional skill to both react and notice our reactions in the moment. This allows us to more precisely notice exactly what the resident is doing that provokes our reaction. Too often we are too close, too immediate, and too personal in our reactions. At these times we sometimes do not even notice our own emotions. In the intensity of the moment we might react like a pinball machine instead of observing, considering, and choosing how to respond as paid, trained professional helpers.

Endearments/Nicknames

Remember that the way you see something is not the same as how the resident may see it. The resident will quite likely interpret events and the meanings of your actions differently from how you mean them. Using terms of endearment can add a gentle and humane touch to a clinical interaction. But it can also create role confusion, and hurt feelings. Calling a resident 'sweetie' or 'honey' may be comforting to that resident, or it might suggest a more personal interest than you intend. It might also point out an element of favoritism to another resident to whom you do not speak that way.

It is a good practice to avoid using endearments and nicknames. These informal terms blur the clarity of your professional role in the life of the resident. You might feel uncomfortable if your doctor refers to you as 'darling' during an exam. You might feel patronized if your attorney called you 'dear'.

Touch

Touch can be healing. It can be comforting, reassuring, encouraging, affirming, or uplifting. Touch can also be confusing, or hurtful, or frightening, or unpleasant, or simply unwelcome. Touch is a powerful tool. It should be used sparingly, and thoughtfully. It should be used for deliberate purposes, and in limited fashion. Touch can serve a good purpose only if you have a clear and good purpose for its use. Residents have different needs and tolerances for touch. When using touch be clear about using it to serve the residents need and not your own. Be mindful about how touch will be experienced and interpreted by the person being touched and the others observing.

Burnout

Healthcare workers make use of themselves as instruments of the helping function. Providing professional help to frail and needy residents can be deeply rewarding, and sometimes deeply draining. Caregivers are notoriously poor at self-care. The kind of giving that leads to burnout tends to be giving done outside of the boundaries of one's job. Being mindful of the limits and boundaries of one's role, and striving to adhere to those role limits helps to safeguard the caregiver from the destructive impact of burnout.

Tone of Voice

Take a moment during your workday and listen to the sounds of the voices around you. Do you hear sounds of annoyance, frustration, exasperation, anxiety, and impatience? Are those sounds coming from the voices of your co-workers? Even our frail and confused residents can understand the emotional qualities conveyed in the sounds of voices. You will also hear sounds that are consoling, encouraging, uplifting, cheering, and reassuring. These comforting tones of voice are helpful and powerful tools to use in the care of residents. We can contribute to an atmosphere of fear or one of caring through the sound of our voice. It is a choice we make every time we speak.

Favorites

It happens all the time. We see examples of it often. But it should not be done. We should not show favoritism in our work with residents. This applies to most favorites as well as least favorites. Of course, we will experience the emotions of attraction towards some residents, and repulsion towards others. But we are obligated to serve all residents with an equal degree of commitment and skillfulness, regardless of our personal reactions. Our residents are counting on our fairness, maturity, and professionalism. And at the times when we are patients ourselves we count on this from our caregivers.

Gifts/Favors

Giving or receiving gifts, or doing special favors can obscure the line between a personal relationship and a professional one. There are times when the loss of role boundaries can do harm to a resident or to a staff person. Abuse would be an extreme example. Disappointment, resentment, confusion and burnout are more common consequences of a chain of small and well-intentioned steps that often begin with special exceptions. If an act of gift giving, or the doing of a favor is outside of the usual and customary activities of one's job, it should be avoided. It may seem awkward to explain that you cannot do the thing a resident is asking. But it becomes easier with practice; and it redraws the clear line that defines the boundary of one's role in the overall care of the resident.

Clothing

Clothes help to define the boundaries of one's role. Clothes communicate messages about how a staff person feels about herself or himself, and about how she or he feels about their role. Certain clothing choices reinforce one's role, or undermine it.

It is important to think about what message you are communicating with your choice of clothing. Outside of work one dresses to highlight personal attractiveness. But at work one should dress to highlight professional sincerity.

Scheduled Time

A professional helping relationship differs from a personal relationship. Personal relationships involve two-way helping. A friend or family member is often expected to be available when needed. But a paid helper is scheduled for particular times. Activities or involvements with a resident outside of scheduled times are an indicator of a blurred boundary.

Observing Behavior as Symptomatic

Too often we emotionally react to the actions of a resident without noticing the way that action is symptomatic of a disorder or disease. It is helpful and instructive to cultivate the ability to see a resident's behavior as symptomatic. Our personal emotional responses can blind us to the meaning of the behavior. Sometimes we react emotionally without fully recognizing that we are reacting emotionally. If we could watch and notice our reactions they could provide us with useful information. But if we reflexively embody our emotions without self-reflection we are likely to miss pertinent information, to lose sight of our role, and to risk causing error.

Do not act on your personal emotions when interacting with a resident. Notice when you are having strong emotional reactions, whether positive or negative. Take a moment to collect yourself. Notice the specific actions of the resident that provoked your emotions. Notice that the resident's action is symptomatic of a disorder condition. Recognize that this action might be the resident's best way to try and solve a problem. You are a professional problem solver. Act from within your helping role and help the resident learn and practice a more successful and adaptive way of addressing their problem or need.

No Romantic/Sexual Relationships

It is never permissible for a professional helper to have a romantic/sexual relationship with a resident.

Secrets

Do not keep secrets with residents. Do not share secrets or ask a resident to keep a secret. Do not agree to keep a secret. Secrets are different from confidentiality. Confidential information is shared with a few others members of a team providing care to a resident. Personal secrets compromise role boundaries. If you avoid charting certain information, or you screen or color information differently for a particular resident, this might be a signal of an existing boundary problem.

A Therapeutic Environment

Acting within role boundaries helps create a therapeutic environment, or what is called a therapeutic milieu. Actions that are appropriate to the function of each person's role help create an atmosphere where all interactions are potentially therapeutic, and in which all persons flourish.

   

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