Subject: Professional Boundaries #212

Revised by: Policy and Procedure Committee

To set forth guidance to professional and paraprofessional caregivers with respect to understanding and maintaining professional boundaries and to delineate the process of managing actual or suspected professional boundary violations.

Professional and paraprofessional caregivers working directly with patients have a responsibility to provide safe, effective and caring services. These staff members must establish a good rapport with patients and provide friendly and accessible services. They are however, responsible for establishing and maintaining appropriate boundaries between themselves and patients. Due to the vulnerability imposed by the patient’s illness and/or disability, the relationship between her/him and the caregiver is not one of equal balance. Both professional and paraprofessional caregivers must recognize and understand that they are in a position of power and that this power must not be abused at any time. It is essential that all interactions between caregiving staff and patients are seen as professional.

Because there is a potential for positions of power to be abused and professional boundaries broken, Nightingale holds its employees fully responsible for maintaining professional boundaries. Ensuring that working relationships are not misread or confused with friendship or other personal relationships protects patients at a time when they are most vulnerable and protects staff from any risk of potential false allegations.

• Boundaries define the limits of behavior that allow a patient and a caregiver to engage safely in a supportive, caring relationship. These boundaries are based on trust, respect and the appropriate use of power.
• The relationship between staff and patients is a therapeutic relationship that must focus solely on the needs of the patient. It is not established to build personal or social contacts for staff. Moving the focus of care away from meeting patient needs toward meeting the needs of the caregiver is an unacceptable abuse of power.

• On occasion, a caregiver may develop an attachment towards a particular patient. While this may be natural, the caregiver should ensure that this does not lead to a breach of professional boundaries. Caregivers should discuss these kinds of feelings/situations with their clinical supervisor.

1. Befriending: Caregivers must never overstep professional boundaries and confuse befriending with

friendship. a. Befriending is a desired element of a professional relationship. It is intended to build trust and ultimately aide in the process of understanding and meeting the patient’s needs. b. Friendship signifies a relationship that focuses on the needs of both people and developing this type of relationship is a potential abuse of power.

a. Professional caregivers must understand the difference between being a counselor and using counseling skills. Using counseling skills, such as active listening is a therapeutic approach to care. b. Counseling exceeds the scope of caregiving for all home health care staff. Patients needing counseling should be given advice and support for accessing counseling services from an appropriate provider.

a. Advice should be limited to areas in which the caregiver is qualified to give such advice, such as areas addressed in the home health plan of care. b. Patients that seek advice outside of the caregiver’s area of qualification and/or scope, should be referred to an appropriate resource.

a. Caregivers must take great care not to attempt to influence patients with their own beliefs and personal values and must remain mindful of their potential to influence patients, who may be in a very vulnerable state. b. Patients may wish to express their views on morality, religion and politics. Caregivers must refrain from promoting or imposing their own views on these topics.

a. Caregivers should be seen as approachable, open to feedback and available to engage in meaningful discussion. Caregivers that are perceived as intimidating or inaccessible should receive this feedback with an open mind and an introspective attitude. b. Patients must not be discouraged from accessing support within appropriate boundaries and must never be discouraged from making a complaint to the agency.

a. Patients’ right to privacy must be respected at all times. b. Assessment of and sensitivity to differing personal and cultural needs for privacy is necessary.

7. Inappropriate Personal Disclosures

: a. Caregivers must refrain from divulging personal information about themselves or other staff

members. b. Patients are often troubled by the personal situations and challenges faced by their caregivers and imparting such information can inappropriately and unnecessarily burden them. It also signals a “give and take” type of relationship which is not exclusively patient-focused.

8. Concealing Information from Colleagues about Patients:

a. Having a “special” relationship where any type of secret is kept signals a boundary violation. b. There are some situations where it is imperative to report findings, including: i. The intention of the patient to hurt self or others ii. The endangerment of a child iii. Any type of violent incident in which the patient or other resident of the home is involved iv. Any critical incident as defined in Nightingale’s policy and procedure for incident reporting

a. Caregivers must approach touching with great care and caution, since patients can misinterpret physical contact as affection outside the professional relationship. Affectionate forms of touching also risk being misunderstood by the patient, potentially resulting in allegations of inappropriate professional behavior. b. Touching must only take place within the context of the professional relationship and with the patient’s permission. c. Caregivers are also advised to maintain a conservative and professional appearance and demeanor at all times to clearly convey to the patient that the relationship is of a professional nature.

1. Financial Interactions/Gift-Giving:

a. Caregivers must not enter into any financial transactions with patients, including buying, selling, exchanging or bartering goods or services. i. This extends to purchasing items to give to patients. Patients with financial or other hardships that impact their ability to acquire needed items should be brought to the attention of management for problem-solving. ii. This also extends to accepting money to purchase items on behalf of patients outside of Nightingale’s established policy and procedures. iii. In cases where private duty patients have negotiated with the agency to have a caregiver shop and run errands for them, caregivers must follow established guidelines for these interactions. (See Policy: Handling Money for Private Duty Patients) b. Caregivers are not permitted to lend money or possessions to patients or borrow money or possessions from patients c. Caregivers are not permitted to become trustees, beneficiaries, will executers or co-owners of any property with/for a patient d. Caregivers must not accept gifts from patients or give gifts to patients

2. Relationships with Patients

a. Where caregivers know potential patients, regardless of how casually, they are required to speak with their clinical manager prior to agreeing to care for that patient to determine whether the assignment is appropriate. b. Caregivers are not permitted to give patients their personal contact information, including but not limited to: address, phone number, fax number, email address or social media address. All necessary communication between caregivers and patients must go through the office. c. Caregivers are not permitted to give patients the contact information of other Nightingale staff members.

d. All staff members are prohibited from “friending” patients on social media web sites. e. Caregivers that encounter patients out in public should be pleasant if approached by the patient, but should generally discourage prolonged social contact. Caregivers should not approach patients in social settings if the contact is not initiated by the patient, especially where the patient’s behavior indicates that s/he does not want to be recognized. f. Caregivers are prohibited from bringing patients with them on their own personal errands or appointments g. Caregivers are not permitted to have contact with patients outside of work. This includes: i. Social contacts of any type ii. Visits to patients while hospitalized iii. Travel with patients to medical or other appointments outside of work time and/or outside of the private duty patient’s plan of care

a. Caregivers are not permitted to introduce their family members, friends or other associates to patients for any purpose. i. Caregivers are not permitted to have spouses, children or other family members accompany them to the homes of patients under any circumstances. ii. This includes having family members give caregivers rides to patient homes for shifts or visits (See HIPAA Policy for further detail) b. Caregivers that are in possession of protected health information must assure that such information is protected at all times in accordance with agency policy. i. Caregivers are not allowed to have family members pick up patient information from the office on their behalf. ii. Caregivers that receive protected health information pertaining to patients at their homes in an electronic format are required to assure that no unauthorized persons are allowed to view the information and that any information that is being discarded is shredded immediately. c. Caregivers are not permitted to discuss patients with other patients under any circumstances. d. Caregivers are not permitted to discuss other staff members with patients except as it pertains to managing care.

Caregivers may unwittingly be drawn into conversations or situations where their boundaries are being stretched or crossed. Caregivers should seek the guidance of their managers if they are unsure about the nature of a relationship with a patient and/or if they need advice on how to deal with a situation.

If the caregiver feels that a colleague is at risk of or has violated professional boundaries in some way, s/he has a duty to protect both the patient and the staff member and should bring the issue to management.

Managers that need assistance with advising a caregiver are expected to seek guidance from their supervisor.

The manager may deem it necessary to discuss boundary issues pertaining to a particular patient with other care team members in order to assure that a consistent approach is taken to managing boundaries with the patient. This will be decided on a case by case basis.

Managers are responsible for general monitoring of these guidelines. Caregiver actions that cross professional boundaries will be reviewed with individual caregivers. Management approaches may include verbal education

and counseling, formulation of written performance improvement plans, and in cases where significant and/or repeated violations have occurred, termination of employment.

All boundary violation complaints are incorporated into the agency’s existing process for reviewing all complaints.