Nurses and other staff in learning disability care may unwittingly or deliberately breach professional boundaries. Education and discussion can help manage this
Healthcare staff providing care for people with a learning disability often deliver intimate personal care and have access to confidential information about vulnerable clients. Awareness of professional boundaries can help them to avoid either under- or over-involvement with patients and clients. Education and reflection can improve staff awareness of boundaries and help them reflect usefully on their relationships with clients.
Citation: Bowler M, Nash P (2014) Professional boundaries in learning disability care. Nursing Times; 110, 12-15.
Authors: Mandy Bowler is clinical business manager; Peter Nash is clinical team lead; both at South Tyneside Foundation Trust.
- This article has been double-blind peer reviewed
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Relationships between healthcare staff and patients develop naturally in many care situations. However, as professional guidance acknowledges, nursing staff can sometimes breach the boundaries of professional relationships, with consequences for the individuals involved (Nursing and Midwifery Council, 2012). Some authors go so far as to state professional boundary crossings and violations are an occupational hazard in nursing and other healthcare professions (Peterneij-Taylor and Yonge, 2003).
Interaction between healthcare workers and patients must be based on assessed clinical need, not personal need, recognising that “boundaries are mutually understood, unspoken, physical and emotional limits of the relationship between the patient and the nurse” (Farber et al, 1997). So whether you are “whining” to a patient about your personal life or accepting a gift, you have altered the role of caregiver to the person in care (Holland, 2013).
Professional boundaries are clearly defined and are based on professional codes of conduct and therapeutic intervention; however, many of the healthcare workers in our learning disability services are non-registered support staff. It is equally important, if not more important since they probably spend more direct one-to-one time with patients, for them to understand and adhere to professional boundaries.
This article gives examples of how South Tyneside Foundation Trust learning disability services support the education and training of staff working within the community and domiciliary care services in maintaining boundaries with patients.
What are boundaries?
There has been recognition of the need for professional boundaries since the beginning of the nursing profession. Lystra Gretter, author of the Florence Nightingale Pledge, in 1893 wrote: “I will abstain from whatever is deleterious and mischievous… maintain and elevate the standard of my profession… will hold in confidence matters committed to my keeping… in the practice of my calling… and devote myself to the welfare of those committed to my care.” (McBurney and Filoromo, 1994)
Boundaries are defined by the NMC (2012) as “the limits of behaviour which allow a nurse or midwife to have a professional relationship with a person in their care” and by the National Council of State Boards of Nursing (1996) as “the spaces between the nurse’s power and the patient’s vulnerability”.
The relationship between a nurse and the person in their care is a professional relationship based on trust, respect and the appropriate use of power.
Boundary issues range from giving or receiving a gift from patients, to picking up groceries for a housebound patient, to social contacts with former patients or their relatives, to having a sexual relationship with patients. While there is guidance for registered health professionals regarding maintaining professional boundaries (NMC, 2012), including sexual boundaries (Council for Healthcare Regulatory Excellence (CHRE), 2009), there does not appear to be anything specific for non-qualified healthcare workers.
Within the community learning disability services at South Tyneside Foundation Trust, we have recognised a need to adopt these principles for non-registered healthcare workers who come into contact with clients and their families. To support their understanding and training, we have developed a framework for one-to-one discussion and supervision, including use of case scenarios. This supports staff in:
- Identifying the differences between professional and personal relationships;
- Understanding professional boundaries;
- Picking up on early signs of boundary issues and taking appropriate action.
Table 1 shows examples of characteristics of professional and personal relationships, that are discussed with the healthcare worker.
Discussions about relationships focus on meeting the health needs of the person in their care. A healthcare worker crosses a professional boundary when they behave in any way that oversteps their professional role with a client in their care, or with a client’s family member or anyone else involved in the client’s care to create a personal relationship. In professional relationships an intimacy may develop as a result of the person receiving the care sharing personal information, feelings and vulnerabilities. This should not be confused with social intimacy.
Perry (2011) argues staff who work in acute care often benefit from having the physical boundaries of a facility to help remind them of their professional boundaries, and from the fact that professional relationships are usually developed in a public arena.
Working within the community learning disability services, most of our staff are home-care providers. This may place them in situations and circumstances where adhering to professional boundaries is more difficult as we cannot always control what happens in a patient’s home. Therefore, it is vital we guide and support our staff not only to protect the patient and family, but also to protect the clinician and the organisation.
The relationship between nurses or healthcare workers and clients is one of unequal power, as the professional carer has authority, knowledge, access to privileged information and influence. It is the responsibility of health professionals to be aware of this imbalance to maintain clear boundaries (CHRE, 2009).
Reasons for power imbalances are:
- That the person in care may have to disclose personal information in order to be diagnosed and have treatment;
- Often it is the health professional who influences the level of intimacy or physical contact during the therapeutic and diagnostic processes;
- The health professional knows what it is that constitutes appropriateness associated with professional practice, but the person receiving the car may not know what is appropriate (CHRE, 2009).
The appropriate use of power in a caring manner enables the healthcare worker to work with the patient to meet the patient’s needs. However, any misuse of that power is considered abuse. Abuse can also mean betraying a patient’s trust, or violating the respect or professional intimacy inherent in the relationship. Abuse may be verbal, emotional, physical, sexual, and financial or take the form of neglect.
Given the imbalance that is inherent in the carer-client relationship within learning disability services, clients often find it difficult to negotiate boundaries or recognise when to defend themselves against boundary violations. The client may be unaware of the need for professional boundaries and therefore may at times initiate behaviour or make requests that overstep the boundaries, so it is up to the healthcare worker to ensure boundaries are respected and maintained.
Crossing these relationship boundaries may not always be clear cut and can sometimes be considered “grey zones” of clinical decision-making where the best course of action is not always obvious (College of Registered Nurses of Nova Scotia, 2002).
Grey zones also exist because such relationships are two-way. For example, a healthcare worker may disclose to a patient that her car is in need of repair but she doesn’t know how she is going to pay for this as her husband is out of work. She mentions that if she doesn’t get her car fixed that she will have difficulty getting to work. The patient then begins to worry about the healthcare worker’s situation, then offers to loan her the money for the repair. This disclosure was inappropriate as it was meeting the needs of the healthcare worker and not those of the patient. The patient may have felt the healthcare worker was looking to her for financial assistance and this caused unnecessary worry for the patient.
As the expectations of the relationship changes and expectations become unclear or unmet, this may cause emotional and psychological harm to the client.
Understanding boundaries in the carer-client relationship
It is important for healthcare workers to be aware when a professional relationship is slipping into the non-professional realm and to take immediate action.
Table 2 gives some examples, by no means exhaustive, of some boundary violations. It attempts to offer guidance on how crossing from professional to personal can be avoided when the healthcare worker is aware of their own behaviour. Therefore ensuring the relationship with the patient is a professional one. A more comprehensive version of this is used in the regular one-to-one discussions and annual personal development planning with staff across our services.
Another measure that is helpful for healthcare workers to determine their relationship with a client is to measure their relationship against the continuum of professional behaviour (Fig 1). The central “zone of helpfulness” is where the majority of client interactions should occur for effectiveness and client safety. Over-involvement with a client, on the right side of this zone, indicates boundary crossings, boundary violations and professional misconduct. Under-involvement, on the left side, includes distancing and neglect and can be detrimental to the client and the carer.
Every carer/client relationship can be plotted on this continuum of professional behaviour and it is an effective tool that the carer can use, with their supervisor, to consider their behaviour.
Box 1 lists some indicators (by no means exhaustive) that may act as warning bells to carers that their behaviour has stepped outside of a professional relationship with the client (Smith et al, 1997). Ticking any of these this would suggest that you have crossed the line from professional to personal and your relationship with the client is becoming or has become blurred - no matter how innocent your intent.
Discussions based upon Tables 1 and 2 and Box 1 are used with healthcare workers during personal development planning and training, and to also reflect on decision-making skills, which may affect professional boundaries. Smyth (1996) advocates that nurses should reflect on their own interactions with patients to understand why they acted or responded the way that they did. Personal values, culture or beliefs can affect how we interact with others and how we respond when others don’t always have the same values or opinions as our own. We have found it useful to reflect on our own thoughts and feelings when reflecting on practice.
Box 2 features two examples of the case scenarios we have used to prompt discussion and examine responses.
If anyone becomes aware that another healthcare worker has, or even may have, breached boundaries then this must be reported to a person of proper authority. The NMC (2012) reinforces nurses’ professional duty to take action to ensure the people in their care are protected, and that any allegations of abuse or suspected abuse are thoroughly and carefully investigated and reported appropriately.
Box 1. Examples of warning bells for carers
- Frequently thinking of the client when away from work
- Frequently planning other clients’ care around that client’s needs
- Seeking social contact with or spending free time with the client
- Sharing personal information or work concerns with the client
- Feeling so strongly about the client’s goals that colleagues’ comments or the client’s or their family’s wishes are disregarded
- Hiding aspects of the relationship with the client from others
- More physical touching than is appropriate or required for the situation
- Romantic or sexual thoughts about the client
Source: Smith et al (1997)
Box 2. Case scenarios
You are a healthcare worker working on a hospital ward. A person with a learning disability with a chronic disease was admitted a month ago and you have become particularly attached to him. His family can only visit infrequently. On his birthday you buy him a present costing £20 and make a cake. He is thrilled. You feel good.
Question - Should you do this, if so why?
Answer - In your enthusiasm to do something special for the person with a learning disability, you independently singled out an individual client. You did not carefully consider the broader implications of giving a gift to this person. As a result, another client on the ward may have felt excluded. Also the giving of a gift can be seen as an attempt by you to create a special, personal relationship beyond the boundaries of the carer-client relationship. The reaction of the family may create an element of mistrust if the family is concerned about you putting them at a disadvantage and alienating them from their family member’s affection.
You have been caring for an older couple at home periodically for many years. Often they serve you a cup of tea and a cookie before you go to your next client. You consider it your coffee break and it gives the couple some much-needed social contact. One day the woman gives you the teacup and saucer to take home. She says: “Because it is yours. You always use it. We are giving away things we can’t take to the nursing home.” When you mention the incident to a colleague. She says: “You should never have taken it. They might later accuse you of theft. In fact, you shouldn’t even accept a cup of tea.”
Question - Is it OK to do this, if so why?
Answer - Accepting a cup of tea and taking time to socialise with this couple can be considered part of the therapeutic plan, but you should not consider it your coffee break because that would be blurring your personal and professional roles. You should confirm each time that it is convenient for the couple. You should not accept the cup and saucer. It may have no monetary value, but it may have value for the family. It is unlikely you would be accused of theft, but is not beyond the realm of possibility. You need to explore the intent of the gift with the couple. Perhaps they view you as their own child and expect an ongoing personal relationship with you. Perhaps it is part of terminating the carer-client relationship. You can then respond to their intent and gracefully decline, explaining you will always have the memories of the couple, but cannot accept the gift. In this scenario you must follow trust policy and can quote it to the couple.
Boundaries must be maintained to ensure safe and effective care is delivered. Our initiative provides a structured framework for exploring the concepts of professional boundaries, and promotes reflective practice and improved decision-making when working with a vulnerable client group.
In the event of a complaint, it is the carer who will need to show they have not abused or exploited any professional relationship. She or he will also need to show any boundary issues have been fully considered and that appropriate advice was sought. We feel the tools discussed give both the healthcare worker and their supervisor support and opportunity to regularly reflect and discuss all carer-client relationships in a structured and formal way. This approach could be adapted for any caregiving environment, to support clinical teams to examine their own professional relationships using reflection and case studies.
- Staff in learning disability services work with vulnerable patients and the risk of professional boundary violations is relatively high
- Boundary violations may range from accepting gifts from patients or families to inappropriate touching or sexual behaviour
- Healthcare workers providing direct patient care need to be aware of professional boundaries
- South Tyneside Foundation Trust’s learning disability service has introduced training and reflection for healthcare workers on professional boundaries
- Consideration of warning signs and use of case scenarios can help staff to reflect on their own relationships with clients
College of Physical Therapists of British Columbia (2009) Where’s The Line? Professional Boundaries in the Therapeutic Relationship.
College of Registered Nurses of Nova Scotia (2002) Professional Boundaries and Expectations for Nurse-Client Relationships. Halifax: CRNNS
Council for Healthcare Regulatory Excellence (2009) Clear Sexual Boundaries Between Healthcare Professionals and Patients: Information for Patients and Carers. London: CHRE.
Farber N et al (1997) Love, boundaries and the patient-physician relationship. Archives of Internal Medicine; 157: 20, 2291-2294.
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National Council of State Boards of Nursing (1996) Professional boundaries: a nurse’s guide to the importance of appropriate professional boundaries.
Nursing and Midwifery Council (2012) Maintaining Boundaries. London: NMC.
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