VOL: 97, ISSUE: 43, PAGE NO: 32
Laura Golding, DClinPsy, DipClinPsy, is consultant clinical psychologist
David Clear, BSc, RNMH, is service manager, at CommuniCare NHS Trust, Blackburn, LancashireThere is a growing awareness within learning disability services that adults with learning disabilities are vulnerable to abuse from staff (Bailey, 1997; Cambridge, 1999). This abuse can take a variety of forms, including sexual, physical, psychological, emotional and financial (Bailey, 1998). In recent years, a number of national initiatives have aimed to work proactively to minimise the likelihood of abuse occurring within learning disability services (Bailey, 1998; Department of Health, 1999).
There is a growing awareness within learning disability services that adults with learning disabilities are vulnerable to abuse from staff (Bailey, 1997; Cambridge, 1999). This abuse can take a variety of forms, including sexual, physical, psychological, emotional and financial (Bailey, 1998). In recent years, a number of national initiatives have aimed to work proactively to minimise the likelihood of abuse occurring within learning disability services (Bailey, 1998; Department of Health, 1999).
Many residential learning disability services are provided by NHS trusts and staffed by nurses and unqualified staff. In most cases, staff work positively and safely with their clients. However, concerns are occasionally raised about the practice of some staff, and this may lead to formal investigations, resulting in disciplinary action.
Nurses and managers can usually identify practices that are clearly unacceptable and should result in disciplinary action (such as striking or sexually abusing a client).
Less clear-cut abusive behaviour can, however, occur because the interpersonal boundaries between staff and clients become blurred. This blurring of boundaries is more insidious, less easy to identify and can be controversial. However, it may be the precursor to more serious abuse, and the early warning signs of abusive practice may not be spotted until abuse has occurred.
This article attempts to explore the issues around the interpersonal boundaries between nurses and adult clients with learning disabilities, and is based on the authors' experience of working in learning disability services. It proposes a framework for understanding how boundaries can become blurred, and highlights the need to develop thoughtful practice, with the aim of minimising the occurrence of abuse.
Although our focus is on learning disability services, the issues discussed here apply equally to all nursing services, particularly those provided for other groups of vulnerable adults.
It has been known for many years that institutions of all types create their particular cultures of abuse (Cambridge, 1999). This includes long-stay hospitals, community services and family units.
Studies seeking to understand the causes of institutional abuse (for example, Martin, 1984) have identified a number of factors that can lead to its occurrence. These include low standards and poor staff morale, weak and ineffective leadership, and a lack of concern about abuse by managers.
In addition, adults with learning disabilities have been shown to be vulnerable to abuse owing to the very nature of their disability. It is known, for example, that people with learning disabilities are more vulnerable to sexual abuse than the general population (Bailey, 1997).
People with learning disabilities share a number of characteristics that increase the likelihood that others will abuse them. In a study comparing 80 abused residential service users who had learning disabilities with 80 non-abused service users, Rusch et al (1986) found six statistically significant 'abuse-provoking characteristics'.
Service users were more likely to have been abused if they could walk, if they displayed aggressive behaviour, if they were young, if they engaged in self-injurious behaviour, if they were non-verbal, and if they were unsociable.
Turk and Brown (1993) found that adults of all ages and levels of learning disability are sexually abused, and that the most likely perpetrators are people known to their victims, including care staff.
These research findings, and others, highlight the vulnerability of many service users to abuse from people they know, and are a reminder of the need for staff to work proactively to reduce the opportunities for abuse.
There is recognition of the need to maintain clear and professional interpersonal boundaries between staff and service users in a number of the caring professions. The UKCC has produced guidelines on relationships with clients, which clearly describe the role of boundaries in professional relationships: 'Boundaries define the limits of behaviour which allow a client and a practitioner to engage safely in a therapeutic caring relationship. These boundaries are based upon trust, respect and the appropriate use of power ... Moving the focus of care away from meeting the client's needs towards meeting the practitioner's own needs is an unacceptable abuse of power' (UKCC, 1999).
Unqualified staff are not bound by the UKCC's guidelines, and are unlikely to have received any training on how to maintain clear interpersonal boundaries between themselves and clients.
This is further complicated by the fact that providing direct care for people with learning disabilities requires staff to adopt many different roles. For example, during a single shift, a member of staff in a residential service may be a 'nurse' (administering medication or coping with seizures), a 'carer' (bathing, brushing teeth, shaving), a 'cook' (preparing meals, shopping for food), a 'friend' (going out with clients to the shops, the pub, for meals, bowling, walks, drives), a 'counsellor' (listening to clients when they are distressed or angry), and a 'parent' (responding to and dealing with clients when they are angry or unmotivated).
Staff often express confusion about their role and managers often disagree among themselves about which practices are acceptable.
The continuum model
One way of understanding the role of interpersonal boundaries is to think of professional behaviour occurring across a continuum.
Fig 1 gives examples of behaviour that would be considered appropriate for care workers (the green area). This represents the behaviour of most staff.
The red area at the other end of the continuum represents behaviour that is obviously not permissible, and should result in disciplinary action.
In the amber area, the interpersonal boundaries between staff and service users are blurred. Examples of staff behaviour that may occur in the amber area include:
- Hugging/kissing service users;
- Accepting hugs/kisses from service users;
- Taking service users to their own home or to the homes of relatives/friends;
- Talking about their personal lives to service users;
- Giving their home telephone numbers to service users or their relatives;
- Staying at work after their shift ends or visiting work when off duty;
- Spouses/family members working in the same part of the service;
- Giving presents to, or accepting them from, service users;
- Arranging service users' holidays to destinations that staff, rather than service users, wish to visit.
These examples highlight the need to raise the awareness of staff and managers about why they do what they do and its possible consequences. For example, it may be appropriate for a member of staff to hug one client and totally inappropriate for them to hug another.
Nurses and unqualified staff make a major contribution to learning disability services. Managers need to encourage a culture in which staff are aware of boundaries, are thoughtful about their actions, and know when to seek advice.
The challenge is not to proscribe practice and work defensively, but to promote an open culture where practice can be observed, questions can be asked and a clear therapeutic rationale can be identified for a blurring of interpersonal boundaries. This could represent a significant step in the right direction towards minimising the occurrence of abuse.