Maintaining Boundaries in Home Health Care

The nurseclient relationship has a natural power imbalance due to the professional knowledge and skills of the nurse that the client relies on for their well-being. Maintaining professional boundaries is part of the nurse's responsibility. Trust, respect, empathy, and power are inherent parts of this nurse-client relationship, with the primary concern for the safety and well-being of the patient.

In home care, the fact that a caregiver is entering a client's home and personal space fosters a sense of familiarity and comfort, but it can also lead to a blurring of duties for the nurse and confusion for the client. The client takes their cues for acceptable behavior based on how the nurse acts and speaks.

The public expects a level of professionalism from a nurse but the sharing of personal stories, discussing things unrelated to the client and their care or even outside the scope of their nursing care plan, such as doing household chores or running errands, can start to complicate the relationship and lead to difficulties in the future.

Boundaries make the relationship professional and safe for the client and establish appropriate limits to the relationship. The more relaxed and familiar the relationship becomes, the more complicated things get, especially if the client is non-compliant and the nurse is faced with the potential discharge from services if they are not meeting their goals and no longer qualify for services. The client may feel betrayed, and those clients or family members familiar with complaint processes could file a complaint with the Board of Nursing, the agency's ownership/management, and even social media.

Many clients appreciate the care and kindness of their nurse and want more than anything to pay them back for the special care they received. The offering of significant gifts (of more than a token value) and their acceptance can often lead to legal issues when family members discover items missing that had been given to the nurse. Many home care managers have received calls from family members, long after their loved one was discharged from the agency, accusing the nurse of taking something belonging to the client despite the client willingly giving it to the nurse. Or, as is often the case, the client merely misplaced it, but the family sees the nurse as the one individual in the home who was the most familiar with and comfortable with the client. These misunderstandings can often lead to police investigations and put the nurses license at risk.

Social media can be dangerous to the nurse/client relationship due to the violation of the federal requirements for client confidentiality just by the mere use of their name, their page, or a picture. There must never be an indication online that the nurse is the client's caregiver, even if they have befriended the client on social media. If there is already a social media connection, pictures should never be posted or any indication of the professional relationship between the client and nurse.

Pediatric home care nurses often become a valuable part of the family unit, but professional boundaries are very easily crossed as the nurse's role and the parent's role often intersect. The parents may ask the nurse to assist in other aspects of the household, especially for those nurses providing extended-hour nursing when the parents may not be home. There is no doubt that an attachment between the nurse and the child can be an easy emotional boundary to cross.

Some may also argue that there is a whole continuum of professional caregiving that extends from an extreme of under involvement, putting vulnerable clients at risk, to being professionally helpful, and then the other extreme of over involvement. There can be intentional or unintentional travel between all of those areas, but the nurse's needs should never be put before the client's. Being friendly is different than being a friend, which implies a mutual relationship.

There is no denying that there is a special bond between the nurse and the client based on trust, mutual respect, and compassion. This relationship can provide care that improves client outcomes and their satisfaction with the services they've received. However, spending more time than is necessary with a particular client or discussing personal or intimate issues with them can be a red flag.

Clients can also become overly involved by asking personal questions, seeking personal information, asking for phone numbers, or behaving inappropriately. It is the nurse's responsibility to re-establish the professional boundaries, but always involve a supervisor or manager who knows and understands the complexities of the nurse's role and can intervene if needed. Document inappropriate behavior and measures taken to reestablish professional boundaries.

Being mindful of boundaries can help protect not only the health and safety of you and your home health clients but also your professional reputation. If you witness or become aware of a breach of professional conduct, it is important to report it as soon as possible to your supervisor or manager. Maintaining these boundaries while remaining friendly can be challenging, but it is essential to foster an environment of trust and safety for your client.

About the Author:

Pamela is an RN with over 45 years of experience. Twenty-five years as an RN and Nursing Supervisor in acute care, ICU, and Med Surg. She was also a clinical nursing instructor for a number of years and then became the Director of Nursing in home health care. Pamela spent over twenty years in home care as an administrator and then President of a large home care and hospice agency, serving approximately 3,500 patients daily and employing 1,000 employees until my retirement. She is also currently an author of continuing education courses for nurses and therapists.

Pamela is an independent contributor to CEUfast's Nursing Blog Program. Please note that the views, thoughts, and opinions expressed in this blog post are solely those of the independent contributor and do not necessarily represent those of CEUfast. This blog post is not medical advice. Always consult with your personal healthcare provider for any health-related questions or concerns.

If you want to learn more about CEUfast's Nursing Blog Program or would like to submit a blog post for consideration, please visit https://ceufast.com/blog/submissions.