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Professional Boundaries for Home Health Care Givers

BoundariesRecognizing and adhering to professional boundaries is extremely important in home healthcare. Professional boundaries can be described as “the spaces between the care giver’s power and the patient’s vulnerability.” At Dakota Travel Nurse Home Care, our care givers receive training and written guidelines to ensure that they don’t over-step established professional guidelines. Whether you are a professional care giver or a family member or friend who is providing in-home patient care, you need to be aware of the lines that separate therapeutic or helping behavior from any behavior that could reduce the benefit of care to patients, clients, families and communities.

Recognizing and respecting professional boundaries may be straight forward in some instances, but research has shown that professional boundaries can be a very complex issue. It is the care giver’s responsibility to set and maintain personal and professional boundaries. The National Council of State Boards of Nursing has identified the ability to establish and maintain therapeutic boundaries with patients as an essential competency.

Continuum of Professional Behavior
Every care giver-patient relationship can be plotted on a continuum of professional behavior. The continuum puts under-involvement at one extreme and over-involvement at the other. Patient-centered care is in the center. This is where patient interactions should occur for effectiveness and patient safety. Over-involvement with a patient includes boundary crossings and boundary violations. Under-involvement includes distancing, disinterest and neglect, and can be detrimental to the patient and the care giver.

Trust, Respect, Intimacy and Power
Interactions in care giver/nurse-patient relationships are characterized by trust, respect, intimacy, and power. Care givers must understand that these characteristics are the basis for their relationships with patients that guide their actions and behaviors.
• Trust: Patients are in a vulnerable position and have to trust the caregiver to provide them with competent, professional care and to avoid personal gratification or financial gain at the patient’s expense.
• Respect: A care giver must treat patients with respect for their individual needs and values, and promote patient autonomy and self-determination.
• Intimacy: The nature of care giving and nursing creates an atmosphere of physical, emotional, and psychological intimacy. Do not interfere in a patient’s personal relationships.
• Power: The professional nurse-patient relationship is one of unequal power; the nurse has authority, knowledge, access to privileged information and influence.

Boundary Violations
Boundary violations occur when there is confusion of the professional’s needs with the client’s needs. They are typically characterized by: a reversal of roles; secrecy; the creation of a double bind (the situation is compromised both by continuing and discontinuing a professional relationship) for the client; and the exercising of personal privilege by the professional. Variables such as the care setting, community influences, patient needs and the nature of therapy affect the delineation of boundaries.

Use of Social Media has potential boundaries issues if it is used to discuss patients, their family or their treatment. Confidentiality should be observed at all times.

Self-disclosure is the sharing of personal information to improve understanding between persons. A care giver may choose to use self-disclosure when it is determined that the information will benefit the client. Self-disclosure must always be provided for the patient’s welfare. It is never acceptable when it is for the purpose of meeting the care giver’s needs.

Giving or accepting gifts may be frowned upon by your employer. DTN Home Care has a strict policy that our staff are not to give or receive gifts. If allowed by your employer, or if you are a friend or family member, giving gifts as an act of gratitude can be part of the therapeutic process. Gifts of gratitude may be an essential part of the patient’s recovery process, while gifts of obligation are usually not acceptable. If a care giver feels coerced or manipulated by the offer of any gift, it should be refused. Gifts that might be misunderstood by either the care giver or the patient should be handled with tact and appreciation. For instance, an offer of money would not be acceptable to a salaried care giver. However, patients and families who wish to give thanks in this manner may be encouraged to donate funds to a charity of mutual choice between the patient and the care giver. Patients must never be given the impression that their care is dependent upon donations of any kind.

Abuse is the misuse of power or a betrayal of trust, respect, or intimacy between the care giver and the patient that may cause physical or emotional harm. Either deliberate or unintentional, abuse in any form is unacceptable and should not be tolerated. Examples include:
• Physical Abuse involves touching or other behaviors that may be reasonably perceived to be violent or to inflict physical harm. Examples of inappropriate behaviors include hitting, scratching, pushing, kicking, using force, biting, pinching, slapping or shaking.
• Physical Restraints in patient care may be considered to be physical abuse. Policies of least restraint should be used in all care settings. That means that all possible alternative interventions are exhausted before deciding to use a restraint.
• Verbal Abuse is communication that includes behavior or remarks toward patients that may be reasonably perceived to be demeaning (sexually or otherwise), seductive, exploitive, insulting, derogatory, and/or humiliating.
• Emotional Abuse involves using verbal and non-verbal behaviors that show disrespect for the patient and that are perceived to be emotionally harmful. Such behaviors can include sarcasm; intimidation; teasing; retaliation; manipulation; inappropriate gestures; insensitivity to the patient’s culture, race, religious practices, economic status, or education; insensitivity to the patient’s preferences with respect to sex and family dynamics; and consciously deciding to withhold information that could contribute to the patient’s well-being. Casual use of terms of endearment such as “dear,” “sweetheart,” and others can also be disrespectful. Addressing people casually without their permission should be discouraged. Call the client by name unless they request to be called by a nickname.
Sexual Abuse. Professional sexual misconduct is an extreme form of boundary violation and includes any behavior that is seductive, sexually demeaning, harassing or reasonably interpreted as sexual by the patient. If the care giver communicates in a flirtatious manner, perhaps employing sexual innuendo, off-color jokes or offensive language, it is a breach of trust.
• Financial Abuse involves taking actions that result in monetary, personal, or other material benefit, gain, or profit to the care giver, or in monetary or personal material loss for the patient. Examples include borrowing money or property from a client; misappropriation of money or property; withholding finances through trickery or theft; forced sale of house or possessions; forced change of a will; influence, pressure, or coercion to obtain the patient’s money or property; abuse of trusteeship, of bank accounts, of power of attorney, or of guardianship.
• Neglect occurs when care givers fail to meet the basic needs of patients who are unable to meet their needs themselves. Such behaviors could include deliberate withholding of basic necessities or care, such as clothing, food, fluid, needed aids of equipment, and medication. Neglect also occurs through inappropriate activities such as withholding communication, confining, isolating or ignoring the patient or denying care or privileges.

Regardless of who is involved in a violation of professional boundaries, it is always the responsibility of care giver(s) to be aware of the situation to act in the best interests of the patient. Boundary crossings need to be evaluated on a case-by-case basis. Certain boundary crossings may be therapeutic. Decisions to cross professional boundaries for therapeutic reasons should be deliberate, time-limited choices that clearly contribute to clients’ care in a beneficial manner. Where the benefit of a boundary crossing is not clear, the care giver must exercise professional judgment to ensure the patient’s welfare.

Warning Signs
Some of the warning signs that professional boundaries need to be reviewed include:
• Frequently thinking of the patient when away from work.
• Frequently planning other patients’ care around one patient’s needs.
• Spending free time with the patient.
• Sharing personal information or work concerns. Keeping secrets with the patient.
• Feeling responsible if the patient’s progress is limited.
• Noticing more physical touching or sexual content in patient interactions than is appropriate.
• Communicating in a guarded and defensive manner when questioned regarding interactions/relationships with the patient.
• Receiving of gifts or continued contact/communication with the patient after discharge.
• Acting and/or feeling possessive about the patient. The nurse believes that the or she is immune from fostering a nontherapeutic relationship and that only he or she understands and can meet the patient’s needs.
• Developing personal relationships with patients who might continue to need nursing services (such as patients with mental health issues or oncology patients).

The brochure that we give our care givers, “A Nurse’s Guide to Professional Boundaries” prepared by the National Council of State Boards of Nursing, and the following link provided many of the tips in this blog. Click http://www.crnns.ca/documents/professionalboundaries.pdf to find more helpful information.

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