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Should CNAs get personal space when...

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Working with residents?

I am not really the touchy-feely type of person, however, I do frequently give hugs to people I like. But, there is one resident at my long term care facility who is in their 80s, and likes to give back rubs to the staff. This person usually sits up by the front nurse's station, and will reach out for staff when we walk by. If we are not busy, many of us will sit down with this person. This person does not see or hear very well, and as a result we must get very close to them, and also talk loudly. The person is usually very pleasant, and has a somewhat wry sense of humor, but can sometimes take things wrong (such as when we are very busy they will see it as if we are avoiding them), and can become tearful.

All these things are fine, understandable, and do not bother me, however, this person INSISTS on touching you, ALL THE TIME. They will reach out for you as you walk by, and if you are talking to them, this person places their hands on your arms, shoulders, face, or hands. None of the touching is inappropriate, but it bothers me. I do not feel comfortable enough with this resident to allow this constant personal touching as if we are related or very close friends, when I am not emotionally attached to this resident, other than concern and care for their well-being.

Due to this resident having a recent injury, they are confined to a wheelchair and need two people to help, where before this person was independent except for occasionally needing help in the morning. This resident seemed often on the verge of tears beforehand, but seems even more upset now, which is understandable. However, I find myself trying to avoid them more than usual, because of their constant touching habits, and the fact that they do not understand their injury. This person thinks they can walk or stand, but once they do, suddenly the pain makes them remember why two people are helping them, and why they are not doing it by themself.

Today, the resident's call light was going off, so I went down to answer it. We were in the middle of shift change, and all the other staff was in report except for me, so when the resident requested to go to the bathroom, I informed them that I could not help unless I had the assistance of one more person. The resident was trying to convince me that I could help them by myself, and I kept saying that "no, we need one more person, and then I can help you." While I was informing them of this, the resident kept reaching out for my face and my shoulders, and I kept veering away while keeping my tone pleasant. I was getting frustrated by the end of the conversation, because my subtle hints were clearly not obvious enough. As the resident was reaching for my shoulder again, I gently pushed their hand away. They responded with a pouting and hurt voice, saying, "I can't even touch you." I said nothing, but informed them to "please wait," and that I would be back. They responded in the same tone, but with some anger, "I guess I'll have to."

Is there a rule anywhere that says people in caregiving professions should give of themselves completely? Frequent touching BOTHERS me. Handshaking, occasional hugs (if I like the person), patting a few times on the shoulder, etc. I can stand, but when it's throughout the ENTIRE conversation, from the second you get there to the moment you walk away, it's WAY TOO MUCH. I do not want to be around this resident, because I do not want to feel like I'm in a petting zoo, like there are no restraints on our relationship. I cannot tell this resident that it bothers me, since because of their poor sight, they may not remember which person dislikes the use of touch, and the resident is not of sound mind - they will likely forget that anyone has a problem with their touching.

Does anyone else in this profession get annoyed by this?
How do you handle residents who do this?
What do you do if they never get the hint, and continue harrassing you with their hands?
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replied July 29th, 2012
Resident invading CNA's personal space
I can understand why you would be uncomfortable. We each have a distance that we like to stand away from others-kind of a "safety zone". If someone gets too close, our instinct is to back away. To answer your question,first I'd like to give you some background information.

The amount of personal space we each need is different for each of us, and it's different depending on the situation or relationship we have with the other person. Also, some cultures like more or less space. It's good that you know how much space you're comfortable with.

There are several different levels of comfortable personal space. Public space is the farthest, and would be like when you're boss is holding a meeting-there is a large space between them and the group. Social space would be when we're with friends or co-workers. Depending on how well we know (and like)the other person, we might stand little closer-or further away. Personal space is when we're with close friends and family- we're comfortable being closer. Intimate space is usually reserved for the people we're closest to and we're comfortable with touching, hugging, etc.

Now think about your relationship with your residents. How close do you stand? Even though we're not family or loved ones, as caregivers, a lot of the time our answer is "Intimate space! To provide care, me must enter the resident's "Intimate space" This can create a lot of problems, especially if the resident has even just a mild cognitive impairment; it's more of problem if the person has dementia. A person with a history of mental illness, "neurosis" or personality disorders can also have "intimate space" difficulties. Have you ever had a patient with dementia become "combative" while you're trying to give them a bath or change their Attends? How about a patient who refused to bathe? We all have. One of the most common causes is that we invaded (or tried to invade) their intimate space!

It seems that with this patient, they're having the opposite reaction. You know that your relationship is a professional one, but they don't. In their mind, you have an intimate relationship, after all you've already seem them undressed, help them in the bathroom, and have possibly touched their private parts. They don't understand why you're "rejecting" them now!

Now that you have some background information about the types of comfortable space & how caregiving crosses into intimate space, what can you do about it?

First, any time there is a behavior problem on a nursing unit you must bring it to the attention of your charge nurse. A behavior plan needs to be developed and shared with all the staff and family members. If it's not, and each caregiver-or each shift-does things differently, the confusion and mixed signals can make the problem worse!

Then, you'll need to figure the "ABC's" of the behavior:

Antecedent (What was happening before the behavior?)
Behavior (What is actually happening?)
Consequence (What happened afterward?)

Some things you'll want to notice:
Does it only happen on the evening or night shifts when the unit's quieting down and there are less people around?
On the weekends?
Right after a family visit-or if they haven't received a visit?
Does the behavior only happen with certain staff? Does that staff person remind the patient of someone significant in their life? Have they treated the patient especially kindly-or "special"? Sometimes we do that without realizing it, which can send the wrong signal.

Something important to remember: Humans are made to have intimate relationships. Could your patient be feeling lonely or craving intimacy? While it is not our role to fulfill a patient's need for an intimate relationship, the need is something to remember; it doesn't go away when a person reaches a certain age or goes into a facility.

After giving the behavior more thought, and have some ideas why it might be happening-what can you do? Your approachl depends on what you've come up with!

First, it's usually easier to prevent the problem than to stop it. For example, if you know that every night, about 9pm, Mr Jones comes down to the nurses station and tries to rub your back. Well, tonight, as you see him coming, you position yourself so he can't get behind you. Maybe stand behind the desk or linen cart. When he's about 10 feet away, greet him and offer your hand. Ask how he's doing and have a little small talk. then tell him how you'd love to talk more, but you must get your work done. Offer him a cup of juice, and help him back to bed, always keeping yourself at arms length and avoid entering "intimate space" if possible. If he tries to touch you, take his hand and step away a little so you're in control of the distance. Gently and professionally, say "Good night, Mr Jones. I'll see you tomorrow evening." If he objects or acts/voices hurt or rejection, acknowledge the feeling with kindness but honesty, "I'm sorry you feel that way, Mr Jones. I didn't mean to hurt your feelings. I enjoy my work as a CNA and enjoy helping you and the other residents. I'll see you tomorrow." Saying this reminds the patient what your relationship is-a professional, helping relationship.

This approach might work-or not. You might need to go back to the drawing board.

All behavior problems should be documented according to "The ABC's": Antecedant (What happens before) Behavior (Who, What Where, When) and Consequence (What happens afterward)

The problem you're having didn't happen overnight-or did it? Any time there's a sudden behavior change it must be addressed immediately-it could be a sign of an urgent medical illness!

but more likely, the behavior you've described has been gradually getting worse over a period of time, so you might need to try a few different things to find something that works. Have patience, be creative and don't be afraid to think outside the box! Remember to never act alone! After listening to all staff members involved, and consulting with the doctor or psychiatrist if needed, your Charge Nurse will develop a plan for everyone to follow. Make sure you document what happened when your followed the plan so it can be reworked if needed. Also, the plan might need to be adjusted at any time along the way. Hope this helps. Pat, RN
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