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Preventing professional boundary violations in aged care

By Julie McStay01 Aug 2009

It is no surprise that the therapeutic nature of the work undertaken in residential and community aged care can create an environment that puts staff and care recipients at risk of professional boundary violations. An effective professional boundaries policy can greatly assist care workers to identify violations which can occur when they place their own needs above the needs of a client and can assist providers to ensure those violations do not occur.

Professional boundary policies

A prudent provider will implement a policy which clearly defines the parameters of the professional relationship and the principles to be applied by all care staff to prevent professional boundary violations. The policy will also state the prescribed standard to which professional boundaries are required and any disciplinary action that will result from breaching these standards.

As a minimum a professional boundaries policy should clearly state that care workers will:

  • not engage in a relationship with clients outside of a professional relationship;
  • regard all information provided to them by a client as confidential;
  • never disclose personal information to a client unless revealing the information has therapeutic value to the client;
  • never use information which they have acquired during the course of their professional relationship with a client to advantage themselves in any way;
  • never withhold care from a client as punishment;
  • never cause or threaten to cause pain, suffering or discomfort to a client to coerce them to act in a certain way; and
  • only touch a client where the touching is necessary to administer care or is part of therapeutic treatment.

The policy will also clearly set out the parameters of permitted conducted with respect to accepting gifts and state that it will never be appropriate to accept a sum of money or a bequest from a client or enter into a financial relationship with a client.

Whilst implementing a well-considered professional boundaries policy is paramount, of equal importance is ensuring that care workers are adequately educated about the policy and regular refresher training is provided accordingly.

In practice

Most providers will have policies and procedures in place which state that professional boundary violations are not permitted. If asked, most care workers will state that they understand professional boundaries and that they must not breach them. However, apart from the most obvious cases of professional boundary violations (for example where a care worker receives a direct and significant gift from a client) there are many more complex scenarios that might arise.

Consider the following examples:

Divulging sensitive information
A care worker has a close relative who is suffering from a significant illness. In the course of caring for a client she discloses her personal situation to the client. The care worker believes in doing so she was helping the client, but the client later revealed that the information disclosed to her by the care worker caused her significant distress.

Unless the disclosure was therapeutic, it was not appropriate.

Beyond employment
A registered nurse provides care services to a frail client in his home for many years. The client has little or no contact from family and friends. The nurse leaves her employment but continues to visit the gentleman. During these visits she discloses to the gentleman that she has some financial issues. The gentleman subsequently offers to lend her some money and she accepts.

The nurse would argue that the therapeutic relationship had ended and that she accepted the loan from a ‘friend’. However given she came to know him in a therapeutic relationship and that relationship had continued for many years in circumstances where he had little contact with others, he was likely to be quite dependent on the contact. If this dependency made the client vulnerable to making decisions to ensure that the contact continued which were decisions he might not otherwise have made, then the conduct may be regarded by a disciplinary body as inappropriate.

Each case of this type will turn on its own facts and the result is likely to be affected by factors such as the length of the therapeutic relationship, the steps taken to inform the client that the therapeutic relationship had ended, the length of the personal relationship which continued after the therapeutic relationship ended and the particular vulnerabilities of the client.

While an organisation can do little to control the actions of a former employee, if such conduct does come to their attention, a prudent provider would subsequently revisit their policies and procedures and provide refresher training to staff.

Perceived preferential care
An aged care worker has developed a fondness for a particular client who has been a resident of the facility for many years. On her birthday the care worker bakes a cake for the client. One of the other clients in the facility becomes resentful that the care worker did not bake her a cake on her birthday.

This conduct may be seen to be an attempt by the care worker to establish a relationship which goes beyond the professional relationship. It also created resentment from another client who may then think she is receiving services to a lesser standard than what others are receiving.

While this is not a significant breach of boundaries it does highlight the possibility that a token action taken with only good intentions still has the potential to create real difficulties in the care environment.

Inappropriate use of position
An aged care worker knows that one of the clients she cares for has a son who is a tradesman. The care worker needs some work done in her home and engages the tradesman. In the course of negotiating price with him she mentions on a number of occasions about how involved she is with his mother’s care.

In this case the care worker is using her position for her own personal gain. The conduct is inappropriate.

Accepting gifts
A resident’s family members regularly present small gifts to a care staff worker on the basis that the particular carer ‘does things so much more nicely for Mum’. At Christmas the client gives the care worker a piece of jewellery which while having sentimental value has little financial value.

It can only be appropriate to accept small gifts if they are merely a token of appreciation and would be unlikely to impact on the professional relationship. It is not appropriate to accept regular gifts if the family think they are 'buying' a higher quality of care for their mother. The care worker should not accept the more significant gift because it could have the potential to impact the professional relationship and it could have a negative impact on other members of the client’s family who had their own expectations about receiving it.

Cultural issues
A client’s son regularly offers small sums of money to a care worker on the basis that in his culture it is appropriate to do so.

Whilst it this may be consistent with the son’s culture it is inappropriate for the individual care worker to accept the money. The money should be returned or, with the consent of the family, donated to the facility.

A closing note

Approved care providers are encouraged to review their existing policies and training programs with respect to professional boundaries to ensure that care workers understand what conduct is permitted and what conduct is not permitted and to identify how to best educate care workers to prevent potential breaches.