Professional Boundaries for the CNA

Boundaries are guidelines, expectations, and rules. They set limits for safe, acceptable, and effective behavior. You learn many of these boundaries in your training and will learn other boundaries in your workplace. As a healthcare worker, you set boundaries between yourself and others. You communicate boundaries by attitude, activity, and communication. Communication is verbal, written, and non-verbal. Non-verbal communication includes facial expressions, body posture, and hand movements.

All humans make mistakes and accidentally cross boundaries. It is important to think about what happened and correct any misunderstandings. It may be as simple as not crossing that boundary again. Other times, talking to the resident about the situation may be needed. Explain the situation to them and explain what you will do differently in the future. It is easy to say I cannot do that because it is a facility rule. However, when you say that, the resident may think you want to do the behavior except for the facility rule. Then, the boundary is not clear. It is better to say, “I want to keep a professional relationship, and that behavior is not appropriate.”

Nurse Setting a Professional Boundary

The residents are vulnerable and dependent on your care. Additionally, you have access to their healthcare and personal information. (Gamble, 2022). So, they think you are more powerful. They may be more willing to do things for you than for non-caregivers because they are afraid of your reaction and possible retaliation. The resident may feel pressured or coerced by you (Levine & Courtois, 2021). Of course, not every resident thinks that way.

First impressions are important. When you present yourself as a professional and show respect, you set boundaries. The workplace is different from social interactions. You are there to do a job, and you need to adopt that attitude when you go to work. The goal is a therapeutic relationship where the resident’s needs are met without more personal relationships. A therapeutic relationship is focused on working with a resident to meet their healthcare needs.

One technique for communicating boundaries is to own your statement. That means when you explain, use the word “I”. For example, “I am not going to do that” or “I do not think that is appropriate.” Another technique is to explain the reason for the boundary. For instance, “We need to keep a professional relationship to focus on the work and protect both of us.”

Showing respect for the resident is one way to establish professional boundaries. This includes routine interactions like:

• Knock-wait for a response. If there is no response, knock again. If there is no response, go in
• Address the resident by name and title
• Introduce yourself (name and title)
• Tell the resident what you are there to do
• Ask for permission to complete the procedure

Therapeutic communication techniques include:

• Respect for the Resident’s Values and Beliefs.
• Allow enough time for each resident to ask questions or voice concerns.
• Offer patience and understanding so the resident feels less anxious.
• Do not lie. Instead, tell them you need to clarify information before you answer and talk to your nursing supervisor for advice or direction.
• Show compassion.
• Be culturally aware.

Residents have normal psychological needs to socialize. They also need to be active to maintain their health. Residents have the right to:

• Make decisions regarding care
  • Planning care
  • Knowing the risks and benefits
  • Refuse or change care
  • Access to medical record
• Make choices about medical care, daily care, what to wear, how to spend their time, and participation in activities with their family
• Privacy and confidentiality
  • Do not discuss the resident with anyone not providing direct care to that resident
  • If the resident loses something in their room, ask their permission to look through their things to find it
  • Residents on a toileting schedule should be approached in a private tone when they are in a group
  • Do not speak to a resident like they are a child
• Dignity, respect, and freedom
  • Freedom from abuse
  • Think about the resident's needs, desires, feelings, and ideas
  • Get permission before looking through the resident’s belongings
  • Knock on the door and wait before entering a resident's room
  • Respond politely to residents
  • Listen to residents
• Security of possessions
  • Manage their finances or assign someone else
• Be informed and consent to transfers of discharges
• Complain without retaliation
• Visits
• Social services

When a caregiver or patient crosses a boundary into a personal or business relationship, that is called a violation. A violation of boundaries can cause confusion and distress for the resident. Behaviors that are violations include:

• Discussing personal issues with a resident
• Flirting
• Keeping secrets with or for a patient
• Thinking you are the only one who understands or can help a patient
• Spending more time with one resident
• Showing favoritism
• Speaking poorly about others
• Meeting a resident outside the normal care setting (Gamble, 2022)

Sometimes, caregivers receive gifts or tips at Christmas or when the resident leaves. That is normal but can be problematic. A very valuable gift can give the impression of a violation between the caregiver and the resident. When you have to turn down a gift, you need to handle it carefully. The gift giver may be upset. Some facilities allow staff to accept gifts for the entire staff, like food or flowers. Be sure to check with your facility.

Physical contact can be misunderstood as a sign of a special relationship, sexual advances, or a threat. Be sensitive to the cultural norms of your residents. In most cultures, touching the hand or lower is nonthreatening and not sexual.

Keep physical contact at a minimum appropriate to your role. Hugs are a common issue, particularly with long-term relationships. If someone unexpectedly hugs you, maintain minimum body contact and explain that hugging is not appropriate to maintain a professional relationship.

People build relationships on shared experiences. Residents are probably interested in your life. Keep personal disclosures to as little as possible. The more in-depth and personal information you share, the more likely it is to violate boundaries.

Consistency at work with the team is necessary. If you bend a rule today, it may cause problems for another worker who tries to enforce boundaries the next day. Residents may use different rules by different workers to exploit the situation and manipulate staff.

When a healthcare worker takes advantage of their resident, it is considered immoral and may be abuse (Levine & Courtois, 2021).

Boundary violations can lead to abuse.Resident complaints should be taken seriously. Take notes and write down what you heard, using the resident’s words. Let the resident know it will be investigated. Then take the information to the manager. Residents often do not complain because they are afraid nothing will be done or the staff may retaliate against them. Adults who are no longer able to care for themselves are vulnerable to abuse or neglect. Abuse is not the right thing to do, and it may be illegal.

• Physical abuse is a physical act that may result in pain, problems, distress, or death. It includes:
  • Striking, hitting, beating, shoving, pushing, shaking, slapping, kicking, pinching, and burning.
  • Forcing residents to eat or drink against their will and,
  • False imprisonment by restraining a dependent adult with drugs or physical restraints.
• Sexual abuse is any sexual act performed with a dependent adult who does not agree to the sex or who is not able to agree to sexual acts. Sexual misconduct is a very extreme form of boundary violation. It is serious and can be criminal.
• Neglect is when the dependent adult does not get the care they need.
• Emotional or psychological abuse is causing anguish, emotional pain, or distress with verbal or nonverbal acts, including:
  • Harassment, verbal assaults,
  • Threats of harm or restraint,
  • Intimidation, humiliation,
  • Involuntary seclusion is isolating a dependent adult from others against their will.
• Spiritual abuse or neglect restricts or prevents a dependent adult from engaging in their usual spiritual activities, customs, or traditions. It also includes making fun of or attacking the person's beliefs.
• Financial abuse is stealing, misusing, or hiding a dependent adult's money or property. Never accept tips or rewards from residents.

Scenario

Mr. J is a resident who touches inappropriately. This was the first time Sue was assigned to be his CNA. While reading the care plan, Sue noticed that inappropriate touching is a chronic problem. “Hello, Mr. J. My name is Sue, and I will be your CNA today. I am going to take your vital signs. Is that OK?” Mr. J agrees. “I am going to pull your privacy curtain, wash my hands, gather my supplies, and I will be right back.” When Sue returns, she starts taking the pulse, keeping physical contact to a minimum. Mr. J. reaches over to pat her butt.

Intervention

Sue moves away and says, “I want to keep a professional relationship, and that behavior is not appropriate. Please do not touch me again.”

Outcome

Mr. J. grumbles but complies.

Strength and Weaknesses

Sue set professional boundaries by acting professionally and respectfully. She minimized physical contact to avoid encouraging Mr. J. She was very clear when objecting to the behavior. In this recurrent situation, the care plan might suggest a statement to Mr. J. before providing care, reminding him not to touch inappropriately.

The CNA should set professional boundaries. The resident may want to please the worker because they depend on the CNA. A therapeutic relationship needs to be maintained, which includes setting and maintaining professional boundaries. Gifts are not acceptable, and physical contact should be kept to a minimum. If boundaries are violated, correct the situation. Boundary violations can lead to dependent adult abuse. When working, maintain a professional attitude and avoid crossing professional boundaries.

• Gamble, J. (2022). Professional boundaries in healthcare: Be aware of these red flags. Nursing Practice, 41(3), 6–7. Visit Source.
• Levine, S. B., & Courtois, C. A. (2021). Boundaries and ethics of professional conduct. In Sexual boundary violations in psychotherapy: Facing therapist indiscretions, transgressions, and misconduct (pp. 45–65). American Psychological Association. Visit Source.