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Congress approves minimal changes to medicare home health benefit
Congress Approves Minimal Changes to Medicare Home Health Benefit Mara Benner
I
n the final hours of the 105th Congress, federal legislators hammered out potential changes to the home health benefit. The negotiations became contentious at times as legislators tried to determine whether anything could be accomplished this year.
As Congress considered the remaining appropriations bill, legislative changes to the interim payment system (IPS) were approved as part of a large funding package known as the Omnibus Reconciliation bill. These changes were agreed to by key committee Republicans, Democrats, and the Clinton Administration and are expected to cost the government approximately $1.7 billion during the next 5 years. Table t outlines the changes that went into effect October I, 1998. These changes helped those home health agencies (HHAs) whose beneficiary limit was below the national median by providing one-third of the difference between the agency’s current per-beneficiary limit and the national median. The legislation does not, however, change the
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current beneficiary national median.
limit
for HHAs
at or above the
New HHAs will see a slight increase from 98% of the national median to a full 100%. Federal legislators still were concerned that new providers will want to start a Medicare home health business. To discourage potential new providers, legislators reduced the per-beneficiary limit to 75% of the national median for providers getting into the Medicare business in or after October 1998. The final legislative package also included a provision from the earlier Senate proposal that postpones the 15% across-the-board reduction in reimbursement. In the Balanced Budget Act (BBA) of 1997, a 15% reduction in both the per-beneficiary limit and the per-visit cost limit was to be effective after October 1999, depending on each HHAs cost-reporting period. The new legislative language has postponed the I 5% reduction until October 2000, and all HHAs will face the reduction on the same date.
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NO. 6
In a last minute change, the Democratic leadership insisted on an extension of the periodic interim payment (PIP) system. In the BBA, the PIP was to be eliminated by October 1999. This elimination was similar to the 15% reduction proposal in that it would take effect depending on each HHAs cost-reporting period. The PIP extension affects all HHAs of October 2000.
IPS. Agency officials said the only provisions that could be implemented were a change of the blend of data in the per-beneficiary limit and an increase in the per-visit cost limits. Other changes, such as a meaningful outlier for the sickest Medicare beneficiaries or other substantive changes, cannot be implemented by HCFA until Y2K issues have been resolved.
Although the changes to the IPS do not harm HHAs, they do little to address the major concerns associated with the system. Because of the current IPS structure, the system continues to:
Another obstacle was whether or not the new legislative changes would be required to be “budget neutral.” Some legislators and the Administration had stated that any changes to the IPS must not include additional government spending. The final legislation, however, did include $1 .i’ billion in government spending. The funding for the legislative changes is paid, in part, by a reduction in the home health market basket. The update in the market basket will be reduced by 1.1% for cost-reporting periods beginning in fiscal years 2000, 2001, 2002, and 2003.
l
l
l
Eliminate the sickest and frailest Medicare from covered home health services Discriminate
against the most cost-efficient
Provide skewed data by which tive payment system
to establish
beneficiaries
HHAs a prospec-
Many congressional members recognized the serious problems associated with IPS and worked hard this year to address them. Charles Grassley (R-IA), John Breaux (D-LA), Max Baucus (D-MT), John Rockefeller (D-WV), Christopher Bond (R-MO), Sue Collins (R-ME), and Connie Mack (R-FL) were a few of the senators who worked hard to rectify the current problems. These legislators were concerned about the impact on the sickest Medicare beneficiaries and the competitive disparities between HHAs. In the House of Representatives, James McGovern (D-MA), Tom Cardin (D-MD), Nancy Johnson (R-VA), Michael Pappas (R-NJ), Pete Stark (D-CA), and Robert name a few of the home health ensure a comprehensive change
The new changes to the IPS provided minimal relief to HHAs, yet several legislators have stated their commitment to working next year for more substantive changes. On the day the legislation passed, one senator in particular clearly stated the need to make further changes. Sen. Charles Grassley stated, “So what’s wrong with (the home health bill)? In short, its increase in payment to low-cost agencies is far too small.. For me, saving those agencies-to preserve access to home care for those they serve-was the foremost reason to act this year. We did not do what we needed to do.”
Bill Thomas (R-CA), Coburn (R-OK), Ben (R-CT), Michael Bliley John Peterson (R-PA), Weygand (D-RI)-to advocates-worked to to IPS this year.
Several obstacles kept the legislators from ultimately passing substantive changes. Earlier in the year, HCFA officials told the legislators that computer concerns related to the year 2000 (Y2K) would keep HCFA officials from accomplishing many BBA provisions. Likewise, HCFA would be unable to make comprehensive changes to the
DECEMBER
1998,
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DECEMBER
1998, VOL. 3 NC
PETERSON
What constitutes healthy boundaries between individuals varies widely, but boundaries may be unhealthy because they are either too tight or too loose. Too-tight boundaries prevent an individual from engaging in open and giving relationships, whereas too-loose boundaries rob the individual of the sense of being a unique person whose needs and wants are separate from others. Boundaries allow us to get close to others yet remain separate. One of the major ways we learn about boundaries is from our families, who teach us separateness and closeness. They also teach us what to call and how to express emotions, an important aspect of developing a sense of uniqueness and intimacy, and they teach us about trusting others. PROFESSIONAL BOUNDARIES What we learned about boundaries as growing children influences how we behave as adults and professionals. In our professional relationships, boundaries take on another level of significance in that they help define and separate professional roles from others. According to Pilette et al.,’ “Boundaries provide security and order.” They also help define and elaborate roles and responsibilities between people. The role of boundaries in professional relationships is especially important because the behavioral norms and standards for other kinds of relationships often do not apply. For example, asking to touch a strangers partially clothed body, asking personal questions about bodily functions, and even entering a stranger’s bedroom all may be necessary aspects of a professional health care role, but they violate societal norms about how we treat other people. Licensure or status provides the initial boundary between professionals and the people they serve. When we re-
DECEMBER
1998,
VOL. 3 NO.
6
ceive professional licensure, we also receive society’s permission to engage in activities or behaviors that otherwise might be considered inappropriate and sometimes even illegal. Licensure helps both the professional and the client know what to expect. Pilette et al.’ remind us about what is true for all professionals as they speak about nurses, “The role charges the nurse with the responsibility of separating and containing his or her needs from the patients’.” In essence, then, licensure allows the professional, because of his or her special expertise, to do certain things that normally would not be permitted but clearly are for the client’s good. Obviously, licensing boards and regulatory agencies cannot promulgate enough laws or regulations (even if anyone wanted them to) to ensure all interpersonal boundaries between the professional and client are clearly defined and specified, so the health professional must rely on additional standards to help identify and prevent boundary violations. A second means of establishing boundaries between clients and health professional is observing professional ethical standards. Most health professions have their own code of ethics that describe appropriate behavior and identify what clients can expect of a health care provider. Some professional codes of ethics clearly prohibit certain behaviors. For example, the National Association of Social Workers code prohibits sexual relationships with clients2 Whether or not a profession’s code delineates specific behaviors as unacceptable, the bottom line for all health professions is to do no harm. Certainly professional, legal, and public opinion would consider having sexual relations with a client as doing considerable harm. As with licensure,
professional standards cannot provide complete guidelines for professional behavior, but they certainly establish some standards for determining ethical behavior. A third means of establishing boundaries between clients and professionals is structuring the relationship to make it professional and not personal. Varcaroli? makes the distinction between personal and professional relationships by delineating three types of relationships: friendship (social), intimate, and therapeutic (professional). She describes a friendship or social relationship as, “Mutual needs are met during social interaction. For example, participants share ideas, feelings, and experiences. Communication skills used in this type of relationship include giving advice and sometimes meeting basic dependency needs, such as loaning money and helping with jobs. During social interactions, roles may shift. Within a social relationship, there is little emphasis on evaluation of the interaction.” She characterizes an intimate relationship, however, by saying, “An intimate relationship occurs between two individuals who have an emotional commitment to each other. Often the relationship is a partnership whereby each member cares about the others needs for growth and satisfaction. Information shared between these individuals may be personal and intimate.” Finally, she says of a professional relationship, “The therapeutic relationship between nurse and client differs from both a social and an intimate relationship in that the nurse maximizes his or her communication skills, understanding of human behaviors, and personal strengths to enhance personal growth in the client. The focus of the relationship is on the client. Roles do not change.”
HOME
CARE PROVIDER
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PETERSON A professional relationship moves through several stages as it progresses, but its goal is to prepare the client and family for the time when they no longer need the health professional. Stuart and Sundeen” describe several relationship stages, three of whichorientation, working, and termination-are important to understand boundaries and will be discussed later in this article. Moving through these stages helps the professional prepare the client and family for a healthy end to the relationship. Taking responsibility for ending the relationship, which includes leaving the client with a plan for how to deal with new problems or the reemergence of old ones, is one of the expectations of a professional relationship and an indication that healthy boundaries are present.
PROFESSIONAL VIOLATIONS
BOUNDARY
Health care professionals must maintain the boundaries between themselves and their clients. This responsibility comes with the privilege of licensure and professional status. When the professional violates a boundary, the very essence of the professional/ client relationship is at risk and almost always the client is at risk for being hurt. In speaking about client/ physician relationships, Linklater and MacDougalP point out, “Patients are caught in a double bind. Clearly they are torn between the desire to terminate the relationship with the physician and the awareness that this termination would end any form of help from the physician.” Boundary violations can take many different forms, but certainly having sexual relations with a client is one of the most serious. As Kagle and GiebelhauserY observe, “Few would argue that sexual relationships between practitioners and clients are ethical.” In many states, a sexual rela-
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responsibilities (eg, a physical therapist buying groceries for the client) 2. ‘Time boundaries: spending more time or unusual time with a particular client (eg, scheduling routinely long visits, seeing the client at bedtime)
tionship between a client and therapist is grounds for malpractice and even is considered a felony in some states. Pilette and colleagues’ say, “Most if not all [boundary] violations are unwitting, subtle, and unconscious. The plight and plea of some patients may persuade some nurses [or other health professionals] to respond in a therapeutically inappropriate way. The seductive pull of helping can make the distinction between appropriate and inappropriate unclear.” Likewise, Linklater and MacDougalP suggest, “Cases of physician/patient sexual misconduct often follow a pattern: minor boundary violations (eg, prolonged mutual conversation instead of client-focused interactions) that escalate into major boundary violations.” Although sexual relationships between the helping person and his or her client may be the most newsworthy, they are not the only kind of boundary violation. Stuart and Sundeen3 describe nine categories of boundary violations. 1. Role boundaries: doing things for the client that are not a part of job
3. Place and space boundaries: providing care in settings other than normal clinical settings. The authors maintain, “Treatment in the car, over lunch, or in the patient’s home must have a good therapeutic rationale and treatment goals.” Although home care involves a legitimate treatment setting, the statement serves as a reminder that boundaries and roles are less clear and definite in someone’s home. As a result, home care professionals may need to be extra cautious about maintaining clear boundaries with their clients. 4. Money boundaries: actions other than normal agency procedures for compensating an employee (eg, seeing a client for free after office hours) 5. Gifts and service boundaries: accepting gifts from a client that are clearly personal and benefit only the employee 6. Clothing seductive that blurs ship with
boundaries: dressing in a manner or in any way the professional relationthe client
7. Language barriers: using too familiar names in addressing each other (eg, first names or nicknames), excessive use of humor, especially suggestive humor 8. Self-disclosure boundaries: disclosing personal information that lacks therapeutic value (eg, a recovering
DECEMBER
1998, VOL. 3 NO. 6
PETERSON chemically dependent nurse routinely telling all similarly dependent patients about her experience) 9. Physical contact boundaries: touching clients in unnecessary or suggestive ways Kagel and GiebelhauseiY conceptualize professional boundary violations in another way. They use the term dual relatio&ps to describe situations in which a boundary violation has occurred or may occur. “A professional enters into a dual relationship whenever he or she assumes a second role with a client, becoming social worker and friend, employer, teacher, business associate, family member, or sex partner. A practitioner can engage in a dual relationship whether the second relationship begins before, during, or after the social work relationship.” This definition means that, any time a health professional has a relationship with a client that is other than professional, at least a serious potential exists for a boundary violation.
THE CLIENT’S ROLE IN BOUNDARY VIOLATIONS Although we again must stress that the health care professional is responsible for maintaining professional boundaries, we need to recognize that clients may behave in ways that make maintaining boundaries more challenging for the health professional. Some clients, with or without diagnosed psychopathology, may have trouble with boundaries themselves. As a result, they may subtly (or not so subtly) act in ways that make it difficult to maintain clearly professional boundaries, such as requesting special favors, asking personal questions, trying to prolong the relationship when it is time to terminate treatment, or actually propositioning the provider. The health care professional must recognize that these types of behaviors
DECEMBER
1998, VOL. 3 NO. 6
may be boundary violations by the client, and the professional needs to maintain clear boundaries, carefully and with good self-awareness, in these situations. Often informal discussions with a coworker or supervisor will help the professional recognize the client’s behavior and develop an approach to deal with the behavior. In other situations, more formal consultation may be necessary to develop strategies to deal with the client or family.
PROFESSIONAL IN HOME CARE
rural setting must have a good understanding of the pitfalls and the positive aspects of dual relationships, With all of the complexities in home care, how do we maintain strong professional boundaries? First, the need for maintaining boundaries in the home setting must be recognized. A health care professional who perceives this challenge will be far better equipped to deal with boundary issues than one who does not even realize the possibility of impropriety.
BOUNDARIES
Maintaining professional boundaries in home care is no small challenge because professional and patient roles may not be as clearly established. This blurring occurs for at least two reasons. First, the setting is the home, not a health care facility. Second, relationships and approaches tend to be more informal and mutual, meaning both the client and the professional must figure out how to relate and what standards apply to their relationship. To further complicate professional boundaries in home care, some care is provided in rural or neighborhood settings in which the professional already has another relationship with the client or family, such as neighbor, fellow church member, or business patron. In this type of situation it may be impossible to avoid dual relationships and still be employed as a health care professional. The National Council of State Boards of Nursing’ reflects on this problem by commenting, “A professional living and working in a remote (or rural) community will, out of necessity, have business and social relationships with clients. Setting standards is very difficult.” However, the strength of some professional relationships is the fact the provider is known in the community. Therefore a professional working in a
Second, the home care provider needs to actively structure the relationship with the client and family to be professional. During the orientation stage, the professional needs to clearly define roles and expectations: “These are the services we provide, but we don’t do. ,” or, “If you need help when I am not here, this is what you should do.” This period is also the time to talk specifically and directly about dual relationships should they exist. No question exists that dual relationships should be avoided whenever possible, especially when they involve giving intimate care or knowing intimate details of another’s life. If duality is unavoidable, it must be talked about regularly throughout the relationship. During the working phase, much of the participants’ focus is on solving the identified problem(s). However, the provider should gently remind the client what the length of service will be and encourage him or her to make plans for what will happen when the relationship ends, Obviously, the professional will work with the client toward this end, but talking about it helps both parties realize the relationship is limited. This discussion also helps strengthen boundaries in the client/professional relationship. If a dual relationship
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PETERSON
about it during the working phase also is important. The health professional needs to make a point of talking to the client about his or her responses to being a part of this relationship, the professionals continued involvement in the relationship, and the ground rules established during orientation. During the termination phase plans, discharge plans need to be implemented, and the actual goodbyes should be said. Often this stage is as difficult for the provider as for the client or family, but it is absolutely essential that the provider say goodbye and mean it. Equally important are ensuring that the client knows whom he or she should call if new or old problems arise and clarifying that any renewed contact will come through a contractual arrangement, not an ongoing, extracurricular relationship with the provider. Third, the provider needs to engage in routine self-assessment. The provider can ask himself or herself several questions, such as: l
l
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Am I dealing with this client or family differently than I would another client or family with similar circumstances? Would I say or do this particular thing if a coworker were present? Would I write this action on the care plan or document this activity as an intervention? Does my behavior with this client differ from my usual professional behavior (eg, dressing differently, being more concerned about appearance, spending more time with a client or family)?
If a provider answers yes to any of these questions, at least the potential
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exists that professional boundaries may be at risk.
REFERENCES 1. Pilette PC, Beck
CB, Acher
LC. Therapeu-
of helping
boundaries.
tic management
Fourth, the provider needs to follow the principle of “when in doubt, ask someone.” Often the provider will have a vague sense that something is not quite right with a particular client relationship but be unable to put into words exactly what the problem or difficulty is. By talking to a coworker, the provider may gain a new perspective on the issue and perhaps brainstorm ways to deal with the concern.
Psychosocial 2. National
of ethics.
tion;
1995;33(
Association
Code
J
1):40-7.
of Social
Workers.
York:The
Associa-
New
1993.
3. Varcarolis and
EM.
Foundations
of psychiatric
mental
health
nursing.
Philadelphia:
WB
Saunders;
2nd
ed.
1994.
p,
125. 4. Stuart
GW,
practices
Sundeen
SJ. Principles
and
of psychiatric
nursing.
5th ed.
St. Louis: Mosby-Year 27-32,
Book;
1995.
p.
58-9.
5. Linklater
D, MacDougall
sues: what cians?
Finally, the provider needs to have a plan in place for dealing with boundary issueswhen they occur. When working in home care, never facing a boundary challenge is almost impossible, so having a plan ready to implement is most wise. Finck” has developed a simple communications mode1 that helps the provider say no to unmeetable requests without being rude, shutting down a conversation, or cutting off the relationship. She suggests saying, “I (or we) can’t do -I but I (we) can do ” For example, “I am not available after 6 PM, but we have an on-call nurse whose phone number I will give you,” or “I cannot pick up your prescriptions at the drugstore, but I can give you the county volunteer services number. They can help you with that.” This approach can be very effective in dealing with such client problems as requesting special favors, calling the provider at home or after hours, asking health-related questions at the grocery store or church, inviting the provider to a family event, or giving the provider money or other gift.
Nursing
do they
Can
mean
S. Boundary
is-
for family
physi-
Fam Physician
1993;39:2569-73. 6. Kagel JD, Giebelhausen ships
and
Work
1994;39:2
7. National ing,
PN.
professional Council
of State
go: The Council
sociation
Social
Boards
of Nurs-
boundaries.
Chica-
1996.
K. Boundary
Proceedings
relation-
13-9.
Inc. Professional
8. Finck
Dual
boundaries.
issues
in home
care.
of Minnesota
Home
Care
meeting;
1996
May;
As-
Brainerd,
Minn.
Elizabeth an
Peterson,
RN,
associateprofessor
Bethel
College
psychiatric
consultant
Caring
and Health
Care
Minn.
Debra
Solomon,
Hospice
MS,
Hospice
coordinator
and a
for
Home-
at Fairview in Chisago
Lakes
RN, nurse
Re-
Lakes, MA,
at HomeCaring
and a family
is
at
in St. Paul, Minn.,
nurse
gional clinical
MA,
of nursing
is the and
practitioner
graduate. Reprint dustrial
orders: Mosby, Inc., I I830 Westline InDr., St. Louis, MO 63 146-33 18; phone
(3 14) 453-4350;
reprint
no. 69/l/95527
The professional/client relationship is unique, one sanctioned by law and reflective of a sacred societal trust. Because of this trust, the health care provider is obligated to protect that relationship and maintain its integral boundaries.
DECEMBER
1998, VOL. 3 NO. 6
I
n the final hours of the 105th Congress, federal legislators hammered out potential changes to the home health benefit. The negotiations became contentious at times as legislators tried to determine whether anything could be accomplished this year.
As Congress considered the remaining appropriations bill, legislative changes to the interim payment system (IPS) were approved as part of a large funding package known as the Omnibus Reconciliation bill. These changes were agreed to by key committee Republicans, Democrats, and the Clinton Administration and are expected to cost the government approximately $1.7 billion during the next 5 years. Table t outlines the changes that went into effect October I, 1998. These changes helped those home health agencies (HHAs) whose beneficiary limit was below the national median by providing one-third of the difference between the agency’s current per-beneficiary limit and the national median. The legislation does not, however, change the
3 12
HOME
CARE PROVIDER
current beneficiary national median.
limit
for HHAs
at or above the
New HHAs will see a slight increase from 98% of the national median to a full 100%. Federal legislators still were concerned that new providers will want to start a Medicare home health business. To discourage potential new providers, legislators reduced the per-beneficiary limit to 75% of the national median for providers getting into the Medicare business in or after October 1998. The final legislative package also included a provision from the earlier Senate proposal that postpones the 15% across-the-board reduction in reimbursement. In the Balanced Budget Act (BBA) of 1997, a 15% reduction in both the per-beneficiary limit and the per-visit cost limit was to be effective after October 1999, depending on each HHAs cost-reporting period. The new legislative language has postponed the I 5% reduction until October 2000, and all HHAs will face the reduction on the same date.
DECEMBER
1998, VOL.
3
NO. 6
In a last minute change, the Democratic leadership insisted on an extension of the periodic interim payment (PIP) system. In the BBA, the PIP was to be eliminated by October 1999. This elimination was similar to the 15% reduction proposal in that it would take effect depending on each HHAs cost-reporting period. The PIP extension affects all HHAs of October 2000.
IPS. Agency officials said the only provisions that could be implemented were a change of the blend of data in the per-beneficiary limit and an increase in the per-visit cost limits. Other changes, such as a meaningful outlier for the sickest Medicare beneficiaries or other substantive changes, cannot be implemented by HCFA until Y2K issues have been resolved.
Although the changes to the IPS do not harm HHAs, they do little to address the major concerns associated with the system. Because of the current IPS structure, the system continues to:
Another obstacle was whether or not the new legislative changes would be required to be “budget neutral.” Some legislators and the Administration had stated that any changes to the IPS must not include additional government spending. The final legislation, however, did include $1 .i’ billion in government spending. The funding for the legislative changes is paid, in part, by a reduction in the home health market basket. The update in the market basket will be reduced by 1.1% for cost-reporting periods beginning in fiscal years 2000, 2001, 2002, and 2003.
l
l
l
Eliminate the sickest and frailest Medicare from covered home health services Discriminate
against the most cost-efficient
Provide skewed data by which tive payment system
to establish
beneficiaries
HHAs a prospec-
Many congressional members recognized the serious problems associated with IPS and worked hard this year to address them. Charles Grassley (R-IA), John Breaux (D-LA), Max Baucus (D-MT), John Rockefeller (D-WV), Christopher Bond (R-MO), Sue Collins (R-ME), and Connie Mack (R-FL) were a few of the senators who worked hard to rectify the current problems. These legislators were concerned about the impact on the sickest Medicare beneficiaries and the competitive disparities between HHAs. In the House of Representatives, James McGovern (D-MA), Tom Cardin (D-MD), Nancy Johnson (R-VA), Michael Pappas (R-NJ), Pete Stark (D-CA), and Robert name a few of the home health ensure a comprehensive change
The new changes to the IPS provided minimal relief to HHAs, yet several legislators have stated their commitment to working next year for more substantive changes. On the day the legislation passed, one senator in particular clearly stated the need to make further changes. Sen. Charles Grassley stated, “So what’s wrong with (the home health bill)? In short, its increase in payment to low-cost agencies is far too small.. For me, saving those agencies-to preserve access to home care for those they serve-was the foremost reason to act this year. We did not do what we needed to do.”
Bill Thomas (R-CA), Coburn (R-OK), Ben (R-CT), Michael Bliley John Peterson (R-PA), Weygand (D-RI)-to advocates-worked to to IPS this year.
Several obstacles kept the legislators from ultimately passing substantive changes. Earlier in the year, HCFA officials told the legislators that computer concerns related to the year 2000 (Y2K) would keep HCFA officials from accomplishing many BBA provisions. Likewise, HCFA would be unable to make comprehensive changes to the
DECEMBER
1998,
VOL. 3 NO. 6
HOME
CARE PROVIDER
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CARE PROVIDER
DECEMBER
1998, VOL. 3 NC
PETERSON
What constitutes healthy boundaries between individuals varies widely, but boundaries may be unhealthy because they are either too tight or too loose. Too-tight boundaries prevent an individual from engaging in open and giving relationships, whereas too-loose boundaries rob the individual of the sense of being a unique person whose needs and wants are separate from others. Boundaries allow us to get close to others yet remain separate. One of the major ways we learn about boundaries is from our families, who teach us separateness and closeness. They also teach us what to call and how to express emotions, an important aspect of developing a sense of uniqueness and intimacy, and they teach us about trusting others. PROFESSIONAL BOUNDARIES What we learned about boundaries as growing children influences how we behave as adults and professionals. In our professional relationships, boundaries take on another level of significance in that they help define and separate professional roles from others. According to Pilette et al.,’ “Boundaries provide security and order.” They also help define and elaborate roles and responsibilities between people. The role of boundaries in professional relationships is especially important because the behavioral norms and standards for other kinds of relationships often do not apply. For example, asking to touch a strangers partially clothed body, asking personal questions about bodily functions, and even entering a stranger’s bedroom all may be necessary aspects of a professional health care role, but they violate societal norms about how we treat other people. Licensure or status provides the initial boundary between professionals and the people they serve. When we re-
DECEMBER
1998,
VOL. 3 NO.
6
ceive professional licensure, we also receive society’s permission to engage in activities or behaviors that otherwise might be considered inappropriate and sometimes even illegal. Licensure helps both the professional and the client know what to expect. Pilette et al.’ remind us about what is true for all professionals as they speak about nurses, “The role charges the nurse with the responsibility of separating and containing his or her needs from the patients’.” In essence, then, licensure allows the professional, because of his or her special expertise, to do certain things that normally would not be permitted but clearly are for the client’s good. Obviously, licensing boards and regulatory agencies cannot promulgate enough laws or regulations (even if anyone wanted them to) to ensure all interpersonal boundaries between the professional and client are clearly defined and specified, so the health professional must rely on additional standards to help identify and prevent boundary violations. A second means of establishing boundaries between clients and health professional is observing professional ethical standards. Most health professions have their own code of ethics that describe appropriate behavior and identify what clients can expect of a health care provider. Some professional codes of ethics clearly prohibit certain behaviors. For example, the National Association of Social Workers code prohibits sexual relationships with clients2 Whether or not a profession’s code delineates specific behaviors as unacceptable, the bottom line for all health professions is to do no harm. Certainly professional, legal, and public opinion would consider having sexual relations with a client as doing considerable harm. As with licensure,
professional standards cannot provide complete guidelines for professional behavior, but they certainly establish some standards for determining ethical behavior. A third means of establishing boundaries between clients and professionals is structuring the relationship to make it professional and not personal. Varcaroli? makes the distinction between personal and professional relationships by delineating three types of relationships: friendship (social), intimate, and therapeutic (professional). She describes a friendship or social relationship as, “Mutual needs are met during social interaction. For example, participants share ideas, feelings, and experiences. Communication skills used in this type of relationship include giving advice and sometimes meeting basic dependency needs, such as loaning money and helping with jobs. During social interactions, roles may shift. Within a social relationship, there is little emphasis on evaluation of the interaction.” She characterizes an intimate relationship, however, by saying, “An intimate relationship occurs between two individuals who have an emotional commitment to each other. Often the relationship is a partnership whereby each member cares about the others needs for growth and satisfaction. Information shared between these individuals may be personal and intimate.” Finally, she says of a professional relationship, “The therapeutic relationship between nurse and client differs from both a social and an intimate relationship in that the nurse maximizes his or her communication skills, understanding of human behaviors, and personal strengths to enhance personal growth in the client. The focus of the relationship is on the client. Roles do not change.”
HOME
CARE PROVIDER
3I5
PETERSON A professional relationship moves through several stages as it progresses, but its goal is to prepare the client and family for the time when they no longer need the health professional. Stuart and Sundeen” describe several relationship stages, three of whichorientation, working, and termination-are important to understand boundaries and will be discussed later in this article. Moving through these stages helps the professional prepare the client and family for a healthy end to the relationship. Taking responsibility for ending the relationship, which includes leaving the client with a plan for how to deal with new problems or the reemergence of old ones, is one of the expectations of a professional relationship and an indication that healthy boundaries are present.
PROFESSIONAL VIOLATIONS
BOUNDARY
Health care professionals must maintain the boundaries between themselves and their clients. This responsibility comes with the privilege of licensure and professional status. When the professional violates a boundary, the very essence of the professional/ client relationship is at risk and almost always the client is at risk for being hurt. In speaking about client/ physician relationships, Linklater and MacDougalP point out, “Patients are caught in a double bind. Clearly they are torn between the desire to terminate the relationship with the physician and the awareness that this termination would end any form of help from the physician.” Boundary violations can take many different forms, but certainly having sexual relations with a client is one of the most serious. As Kagle and GiebelhauserY observe, “Few would argue that sexual relationships between practitioners and clients are ethical.” In many states, a sexual rela-
3 16
HOME
CARE PROVIDER
responsibilities (eg, a physical therapist buying groceries for the client) 2. ‘Time boundaries: spending more time or unusual time with a particular client (eg, scheduling routinely long visits, seeing the client at bedtime)
tionship between a client and therapist is grounds for malpractice and even is considered a felony in some states. Pilette and colleagues’ say, “Most if not all [boundary] violations are unwitting, subtle, and unconscious. The plight and plea of some patients may persuade some nurses [or other health professionals] to respond in a therapeutically inappropriate way. The seductive pull of helping can make the distinction between appropriate and inappropriate unclear.” Likewise, Linklater and MacDougalP suggest, “Cases of physician/patient sexual misconduct often follow a pattern: minor boundary violations (eg, prolonged mutual conversation instead of client-focused interactions) that escalate into major boundary violations.” Although sexual relationships between the helping person and his or her client may be the most newsworthy, they are not the only kind of boundary violation. Stuart and Sundeen3 describe nine categories of boundary violations. 1. Role boundaries: doing things for the client that are not a part of job
3. Place and space boundaries: providing care in settings other than normal clinical settings. The authors maintain, “Treatment in the car, over lunch, or in the patient’s home must have a good therapeutic rationale and treatment goals.” Although home care involves a legitimate treatment setting, the statement serves as a reminder that boundaries and roles are less clear and definite in someone’s home. As a result, home care professionals may need to be extra cautious about maintaining clear boundaries with their clients. 4. Money boundaries: actions other than normal agency procedures for compensating an employee (eg, seeing a client for free after office hours) 5. Gifts and service boundaries: accepting gifts from a client that are clearly personal and benefit only the employee 6. Clothing seductive that blurs ship with
boundaries: dressing in a manner or in any way the professional relationthe client
7. Language barriers: using too familiar names in addressing each other (eg, first names or nicknames), excessive use of humor, especially suggestive humor 8. Self-disclosure boundaries: disclosing personal information that lacks therapeutic value (eg, a recovering
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PETERSON chemically dependent nurse routinely telling all similarly dependent patients about her experience) 9. Physical contact boundaries: touching clients in unnecessary or suggestive ways Kagel and GiebelhauseiY conceptualize professional boundary violations in another way. They use the term dual relatio&ps to describe situations in which a boundary violation has occurred or may occur. “A professional enters into a dual relationship whenever he or she assumes a second role with a client, becoming social worker and friend, employer, teacher, business associate, family member, or sex partner. A practitioner can engage in a dual relationship whether the second relationship begins before, during, or after the social work relationship.” This definition means that, any time a health professional has a relationship with a client that is other than professional, at least a serious potential exists for a boundary violation.
THE CLIENT’S ROLE IN BOUNDARY VIOLATIONS Although we again must stress that the health care professional is responsible for maintaining professional boundaries, we need to recognize that clients may behave in ways that make maintaining boundaries more challenging for the health professional. Some clients, with or without diagnosed psychopathology, may have trouble with boundaries themselves. As a result, they may subtly (or not so subtly) act in ways that make it difficult to maintain clearly professional boundaries, such as requesting special favors, asking personal questions, trying to prolong the relationship when it is time to terminate treatment, or actually propositioning the provider. The health care professional must recognize that these types of behaviors
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may be boundary violations by the client, and the professional needs to maintain clear boundaries, carefully and with good self-awareness, in these situations. Often informal discussions with a coworker or supervisor will help the professional recognize the client’s behavior and develop an approach to deal with the behavior. In other situations, more formal consultation may be necessary to develop strategies to deal with the client or family.
PROFESSIONAL IN HOME CARE
rural setting must have a good understanding of the pitfalls and the positive aspects of dual relationships, With all of the complexities in home care, how do we maintain strong professional boundaries? First, the need for maintaining boundaries in the home setting must be recognized. A health care professional who perceives this challenge will be far better equipped to deal with boundary issues than one who does not even realize the possibility of impropriety.
BOUNDARIES
Maintaining professional boundaries in home care is no small challenge because professional and patient roles may not be as clearly established. This blurring occurs for at least two reasons. First, the setting is the home, not a health care facility. Second, relationships and approaches tend to be more informal and mutual, meaning both the client and the professional must figure out how to relate and what standards apply to their relationship. To further complicate professional boundaries in home care, some care is provided in rural or neighborhood settings in which the professional already has another relationship with the client or family, such as neighbor, fellow church member, or business patron. In this type of situation it may be impossible to avoid dual relationships and still be employed as a health care professional. The National Council of State Boards of Nursing’ reflects on this problem by commenting, “A professional living and working in a remote (or rural) community will, out of necessity, have business and social relationships with clients. Setting standards is very difficult.” However, the strength of some professional relationships is the fact the provider is known in the community. Therefore a professional working in a
Second, the home care provider needs to actively structure the relationship with the client and family to be professional. During the orientation stage, the professional needs to clearly define roles and expectations: “These are the services we provide, but we don’t do. ,” or, “If you need help when I am not here, this is what you should do.” This period is also the time to talk specifically and directly about dual relationships should they exist. No question exists that dual relationships should be avoided whenever possible, especially when they involve giving intimate care or knowing intimate details of another’s life. If duality is unavoidable, it must be talked about regularly throughout the relationship. During the working phase, much of the participants’ focus is on solving the identified problem(s). However, the provider should gently remind the client what the length of service will be and encourage him or her to make plans for what will happen when the relationship ends, Obviously, the professional will work with the client toward this end, but talking about it helps both parties realize the relationship is limited. This discussion also helps strengthen boundaries in the client/professional relationship. If a dual relationship
HOME
exists, talking
CARE PROVIDER
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PETERSON
about it during the working phase also is important. The health professional needs to make a point of talking to the client about his or her responses to being a part of this relationship, the professionals continued involvement in the relationship, and the ground rules established during orientation. During the termination phase plans, discharge plans need to be implemented, and the actual goodbyes should be said. Often this stage is as difficult for the provider as for the client or family, but it is absolutely essential that the provider say goodbye and mean it. Equally important are ensuring that the client knows whom he or she should call if new or old problems arise and clarifying that any renewed contact will come through a contractual arrangement, not an ongoing, extracurricular relationship with the provider. Third, the provider needs to engage in routine self-assessment. The provider can ask himself or herself several questions, such as: l
l
l
l
Am I dealing with this client or family differently than I would another client or family with similar circumstances? Would I say or do this particular thing if a coworker were present? Would I write this action on the care plan or document this activity as an intervention? Does my behavior with this client differ from my usual professional behavior (eg, dressing differently, being more concerned about appearance, spending more time with a client or family)?
If a provider answers yes to any of these questions, at least the potential
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CARE PROVIDER
exists that professional boundaries may be at risk.
REFERENCES 1. Pilette PC, Beck
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LC. Therapeu-
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Fourth, the provider needs to follow the principle of “when in doubt, ask someone.” Often the provider will have a vague sense that something is not quite right with a particular client relationship but be unable to put into words exactly what the problem or difficulty is. By talking to a coworker, the provider may gain a new perspective on the issue and perhaps brainstorm ways to deal with the concern.
Psychosocial 2. National
of ethics.
tion;
1995;33(
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of Social
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Finally, the provider needs to have a plan in place for dealing with boundary issueswhen they occur. When working in home care, never facing a boundary challenge is almost impossible, so having a plan ready to implement is most wise. Finck” has developed a simple communications mode1 that helps the provider say no to unmeetable requests without being rude, shutting down a conversation, or cutting off the relationship. She suggests saying, “I (or we) can’t do -I but I (we) can do ” For example, “I am not available after 6 PM, but we have an on-call nurse whose phone number I will give you,” or “I cannot pick up your prescriptions at the drugstore, but I can give you the county volunteer services number. They can help you with that.” This approach can be very effective in dealing with such client problems as requesting special favors, calling the provider at home or after hours, asking health-related questions at the grocery store or church, inviting the provider to a family event, or giving the provider money or other gift.
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The professional/client relationship is unique, one sanctioned by law and reflective of a sacred societal trust. Because of this trust, the health care provider is obligated to protect that relationship and maintain its integral boundaries.
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