Professional boundaries: Dancing on the line

“But she told me I could have it.”

“It was only $5 and he gave it to me!”

Sound familiar? I recall one home health aide who took an entire set of expensive china from a client. Of course, the family reported it to us. When we brought the employee to discuss the situation she saw absolutely nothing wrong with it – she said the client gave it to her and wanted her to have it – in spite of the fact that the client was forgetful.

Health care, by its very nature, engages the worker in intimate treatment. Workers are at risk for inappropriate client/worker relationships due to the broadening scope of health care settings such as community health practices (Assisted Living, Home care, independent practices) amidst rapid societal changes and pressures.  The complexities of health care relationships have outpaced awareness of ethical considerations of boundary issues.

In community health settings, the risk of crossing the line of professional boundaries is at a greater risk than in institutional settings for a variety of reasons:

  • Typically there is one-on-one care resulting in the client and the worker getting to know each other on a more intimate basis.
  • It is not unusual for topics to turn to a more personal level.
  • The worker is often less rushed to complete tasks and move on to the next patient.
  • In the interest of continuity of care, it is often the same worker who cares for the client most of the time.
  • In community health, the worker is more independent and autonomous in his or her practice.

The care plan is developed by the professional with input is provided by the client and tasks often include specific requests from the client. The risk is that the client may add tasks that are not part of the care plan. And the care plan, in some cases, may involve tasks such as grocery shopping, laundry and meal preparation – the worker is asked to satisfy a variety of needs for the client – unlike an institutional setting where such tasks would be divided among workers from various departments. This sets the foundation for a closer relationship.

In many settings, such as home health, there is no continual direct supervision. Therefore, the worker has to use common sense and good judgment in a variety of situations.

Workers who lack knowledge about boundaries and certainly those lacking ethics related to boundaries are in a position to cross over the boundaries to a greater extend and for a longer period of time than those under continual direct supervision.

Increasingly, reports of inappropriate relationships between professionals and patients or clients are being brought to the Board of Nursing and the Minnesota Nurses Association. So too are incidents of boundary issues with the paraprofessionals. This emphasizes the need for more in-depth training on boundary issues.

Often times there is little conversation related to boundary expectations. No conversation with the worker or with the client. Without expectations being set, both the client and worker rely on personal judgment – not always an ideal situation.

Health care workers are in a unique position of power by default. The client is dependent on the worker for cares and advice. They look upon the health worker – especially professionals – as “having the answers.”  This emphasizes the need for ongoing training on boundaries.

When is the last time you provided specific training on boundary issues? It is important to set boundaries with your clients as well as your staff. Provide information in writing for clients and employees so that they can refer to it periodically. Role-play with staff and discuss “real life” situations. You may be surprised about what your staff reveals. It is a perfect opportunity to provide education and eliminate misconceptions.

Need help? Check out the “Boundaries and You” video at www.AcornsEnd.com.

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One thought on “Professional boundaries: Dancing on the line

  1. Pingback: Friday Round-up « Minnesota HomeCare Association's Nurse Consultant BLOG

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