FACILITY
SAMPLE Professional Relationships Guideline: Training Guideline
DEFINITIONS:
What is a relationship? A relationship is a relatively long term association between two or more people.
This association may be based on emotions like love and liking, family/kinship, regular business
interactions, or some other type of social commitment. In interpersonal relationships, boundaries may
range from strict to very open.
What is a professional relationship? A professional relationship is an association between two or more
people, whether short or long term, that is based on the provision of services by the professional.
Boundaries in professional relationships are based on providing service to the client/resident in a safe and
appropriate manner, and are often defined by professional ethics codes.
What is a boundary? Something that indicates a border or limit. Professional boundaries define what is
therapeutic from what is not. Professional boundaries may be defined by:
o General Law – e.g., hitting is battery, stealing is a crime
o Professional associations – e.g., American Nurses Association, American Medical Association,
National Association of Social Workers, American Psychological Association, or others
o Your licensing authority – e.g., CA Board of Nursing, CA Medical Board, etc.
o Facility policy and procedure
Another definition is from the American Nurses Association Ethics Code
Professional Boundaries – When acting within one’s role as a professional, the facility staff member
recognizes and maintains boundaries that establish appropriate limits to relationships. While the nature of
nursing work has an inherently personal component, nurse-resident relationships and nurse-colleague
relationships have, as their foundation, the purpose of preventing illness, alleviating suffering, and
protecting, promoting, and restoring the health of residents. In this way, nurse-resident and nursecolleague relationships differ from those that are purely personal and unstructured, such as friendship.
The intimate nature of nursing care, the involvement of nurses is important and sometimes highly
stressful life events and the mutual dependence of colleagues working in close concert all present the
potential for blurring of limits to professional relationships. Maintaining authenticity and expressing
oneself as an individual, while remaining within the bounds established by the purpose of the relationship
can be especially difficult in prolonged or long term relationships. In all encounters, nurses and all other
staff are responsible for retaining their professional boundaries. When those professional boundaries are
jeopardized, the nurse/facility staff should seek assistance from peers or supervisors or take appropriate
steps to remove her/himself from the situation.
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The National Council of State Boards of Nursing provides the following diagram of appropriate
boundaries: A Continuum of Professional Behavior
Under-involved
Zone of Helpfulness
Over-involved
A zone of helpfulness is in the center of the professional behavior continuum. This zone is where the
majority of client interactions should occur for effectiveness and client safety. Over-involvement
with a client is to the right side of the continuum; this includes boundary crossings, boundary
violations and professional sexual misconduct. Under-involvement lies on the left side; this includes
distancing, disinterest, and neglect and it can also be detrimental to the client and the nurse. There are
no definite lines separating the zone of helpfulness from the ends of the continuum; instead it is a
gradual transition or melding.
How do I know if I’m maintaining a professional relationship? As the ANA ethics code notes, it is
difficult to maintain professional boundaries, especially when providing intimate care in a long term
setting. On the one hand, you should always ask “is this part of my job?” This is not to say that we only
relate to residents based on job tasks, but if an act is clearly outside of the job, you should question it.
There are some behaviors we can think of which clearly are wrong: stealing from residents, having sexual
relationships with them, borrowing money from them. However, most of the problems we encounter are
not so obvious.
EXAMPLES of boundary violations:
 “Mr. A asked me to pick up a burrito for him,” “I gave him the rest of my burrito from lunch.” This also
applies to sharing or lending cigarettes or to buying things for residents outside of work.
 Potential issues: Resident is on a special diet, other residents now want the same; Resident is
asking other staff and he “doesn’t like them anymore” if they don’t agree; You are doing residentrelated activities on break time, or doing personal activities on work time, time in this task takes
away from other tasks which are required; Regulations specify how food is stored and prepared—
if resident gets food poisoning you are negligent; No one can take money from a resident unless
they are operating through FACILITY policies and procedures for purchases with the possible
exception of putting money in front of a resident into a soda machine while they are watching to
purchase them a soda (but make sure the soda is appropriate for their medical condition before
you help at all!)
 What to say/do: I am sorry that I can’t do that –it’s important for me not to mix my work and
break times. We have individuals at FACILITY who assist residents in purchases—refer them to
them.
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 “I gave Mrs. B my personal e-mail; she worries a lot, and I can answer questions so she doesn’t worry
so much”
 Potential issues: Strongly suggests the relationship is moving from professional to personal;
Resident is now asking this staff member for professional advice that is beyond the scope of their
practice; Doing work activities on personal time, resident is not communicating with the team;
Resident is mad at me and now I’m getting harassed
 What to say/do: Ask resident not to use personal email. May send innocuous emails from the
county computer during work hours if part of rehab as specified by IDT.
 “Mr. C bought me some nice clothes for my birthday”
 Potential issues: Resident may have a romantic or sexual interest and a gift of clothing is too
personal; Accepting items from residents can be seen as exploitation of a dependent adult;
Resident is now asking me for favors and I feel indebted
 What to do/say: It is nice to think of me, but I cannot accept gifts from residents. I appreciate the
thought and your generosity and appreciation. I care for you, too!
 “Mrs. D asked me for a quarter and I gave it to her”
 Potential issues: Resident using money from multiple people to purchase items that they are not
allowed to have, or are potentially harmful to them; Resident becomes a behavioral problem due
to constant pressuring of staff and peers for money
 What to say/do: I don’t have money to give to you. Staff is not allowed to give money to
residents.
 “I’m going to the Fair this weekend. Mr. E. really wants to go so I’ll take him”
 Potential issues: Strongly suggests the relationship is moving from professional to personal;
Serious liability risk and blurring of responsibility (e.g., resident gets hurt – whose insurance
covers the injury? If you get hurt, is it a workers comp claim?); Now other residents want the
same
 What to say/do: I know going to the fair is important to you. Have you talked with the TR or SW
about how you might be able to get there? What do you like to see or do there? I love the Ferris
wheel!
 “My computer broke and Mrs. F is loaning me her laptop”
 Potential issues: May constitute exploitation of a dependent adult; I broke it and can’t afford a
new one; Resident is angry at me now and is saying I stole it
 What to say/do: Return it at once.
 Staff teases or antagonizes the resident, e.g., name-calling, telling the resident things to intentionally
upset them, intentionally being late for care.
 Potential issues: May constitute abuse of a dependent adult; what is funny to one is not funny to
another and outsiders overhearing may misconstrue what is being sai; Many demented people do
not understand jokes; Resident escalates and hits, yells, throws objects, etc.
 I agree that Susie CNA isn’t as good as I am—she is having marital problems and I hear her husband is
a drunk. I wouldn’t trust her either.
 Potential issues: Telling residents about your personal problems, marriage issues, issues with
other staff constitute violations of professional boundaries. Professional boundaries say that we
protect our own and other’s privacy in dealing with residents.
 What to say/do: Do not discuss these issues.
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 “Mr. G needs to sell his car; I’ll buy it since I need a car and it will help him out”
 Potential issues: May constitute exploitation of a dependent adult; Resident may later say you
“pressured them;” The car is a “lemon” and I want my money back, but the resident refuses
 What to say/do: NEVER buy something from a resident or sell something to them.
The following are examples of boundary violations, but these relate to not caring enough and are
neglect:
 “Mrs. H is really angry; doesn’t like me; “fired” me; so I’m not going in there.”
 Potential issues: We have a duty to care for our residents, and not doing so is neglect; if there is a
bad outcome, YOU and the facility will be liable
 “Mr. I is a demanding #%$&! They can just wait.”
 Potential issues: Regardless of our feelings toward a resident, we have a duty to provide care.
Not doing so is neglect. Note: if there is danger, or the resident is really unmanageable, get help
and talk to your supervisor
 “Mrs. J is a #%$&! I’m not going to take care of them.”
 Potential issues: Not caring for a resident because you don’t like them is neglect.
If they agree to it, what’s the problem? Remember, any resident at FACILITY is by definition a
dependent adult. Laws about abuse, neglect, and exploitation apply. Also, most of our residents have
some degree of cognitive impairment and many do not have decision-making capacity. Even if they do,
our residents are vulnerable and depend on us. As a result they are never on an equal footing in any sort of
agreement – our position gives us power.
This seems really strict. How can we have a “caring relationship?” While there are many limitations
on professional relationships, we do want to express caring, and the relationships we have with residents
are often among the most important ones they have. We do not want to be too cold or clinical, and it is
good to smile, talk with residents, and even sometimes to engage in gift giving or touch.
EXAMPLES of things that are “OK”
 “Mrs. A made me a frog in ceramics”
 “Mr. B has pictures of his grandchildren; we talked about them and I mentioned mine”
 “Mrs. C was crying; I held her hand”
 “Some of the residents and I were talking about the Chargers game”
 “Mr. D needs shoes. I have an old pair that would fit and I’m bringing them in for him” (After
consulting with IDT members.)
 “We’re setting up a program to give holiday gifts to the residents” (Should be designed to make sure all
residents get a gift, and that they are of similar value. Ideally, this should be designed to avoid
identifying “favorites” or conveying dislike.)
 “We bought Mrs. E a birthday card.” (Should be reviewed by IDT and of minimal value or using
facility materials.)
What if I’m not sure? Ask your supervisor or other staff that can help clarify what is appropriate.
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