Can appropriate boundaries be rebuilt?

caliotter3 · Apr 21, 2012

Money changed hands? Sorry, but I would have removed the CNA from the case as soon as I learned of that, and I probably would have terminated her employment.

JustBeachyNurse, LPN · Apr 21, 2012

The behavior you describe is grounds for immediate termination in my agency. Plus some education for the family. An outsider or investigator can perceive her actions as taking advantage of a vulnerable family which in turn can result in fines and sanctions against the agency. The cash acceptance is a huge ethical issue. As soon as you were alerted (by the cna, the family, or another staff member?) you should have put an end to the situation. I was under the impression cna's were required to undergo hha training (a short conversion course) which specifically details the additional conditions that happen in a home environment such as family meals and professional boundaries that may not occur in a hospital or LTC setting.

elkpark · Apr 21, 2012

I'm considering removing her from the case, educating her on boundaries, and placing her elsewhere. That could leave the next Aide open to the same temptations and perhaps cause the client to leave the agency.
Thoughts?

She's still working with that family?? Holy moley. If you really feel she's worth "salvaging" and you don't want to just fire her, she should at the very least no longer be on that case (or on any case until she has been remediated about boundaries and professional expectations and you are satisfied she has gotten the message). And, if you're worried about another CNA succumbing to the "same temptations," it sounds like some serious agency-wide eduation is in order.

tcvnurse, BSN, RN · Apr 22, 2012

She should be terminated. Unbelieveable she hasn't been canned yet.

allnurses Guide · Apr 22, 2012

I think it's best if an HHA or nurse not combine friendship with the client and also be an employee of a third party. From what I've seen, this boundary-crossing is pretty rampant. There have been times when someone will have a concern about a boundary issue that is relatively minor when weighed against the impact severing that relationship could have on the client/family.

Families have a natural impulse to give things to longtime or trusted caregivers. If it's a birthday, I wouldn't refuse a piece of cake. I had one client who was so self-conscious about how long it took to feed by mouth, they were literally relieved if I had a plate nearby - which I rarely ate much of because it made me feel self-conscious! Many of them have non-agency caregivers that become very embroiled in each other's lives and it can be hard for them to think of them differently.

Things of substantial value changing hands shouldn't happen. Can the boundaries be rebuilt? Most likely not.

KateRN1 · Apr 22, 2012

I have a power point presentation that specifically addresses boundaries in home health care. If you'd like a copy of it, feel free to email me at katern1 at hotmail dot com.

kparry · Apr 23, 2012

Thank you for a real world answer. You have actually nailed the situation precisely.

...From what I've seen, this boundary-crossing is pretty rampant. There have been times when someone will have a concern about a boundary issue that is relatively minor when weighed against the impact severing that relationship could have on the client/family.
Families have a natural impulse to give things to longtime or trusted caregivers.
...Many of them have non-agency caregivers that become very embroiled in each other's lives and it can be hard for them to think of them differently.

I see client's families so in need of help, and so thankful they receive it, that they then feel the very natural emotion to give in return.

The CNA came to me to ask what to do. The gifts started out small... she donated the clothes... Christmas was the cash gift... she felt like she would offend the family if she didn't accept the invitation to Easter dinner. A good chance no one would ever have known had the CNA not come to me for guidance.

As a Companion I was removed from a case and subsequently lost my job because a family fed me and an Alzheimers patient together. The client would eat better if she thought I was a friend and we were sharing a meal.

I'm suprised no one suggested notifying the BoN which is probably also appropriate ...sigh... No winners here. CNA has discipline against her license, agency loses a client and staff, client loses a compassionate and proficient caregiver.

allnurses Guide · Apr 23, 2012

Thanks, and I really feel for all the people involved here. Best wishes whatever you decide. I hate it that sometimes things boil down to not-so-good and worse in the decision making process. Keep us updated if you get the chance. We get so few chances to share our experiences because our workplace environment is diffused in so many locations.

JustBeachyNurse, LPN · Apr 23, 2012

Thank you for a real world answer. You have actually nailed the situation precisely.
I see client's families so in need of help, and so thankful they receive it, that they then feel the very natural emotion to give in return.
The CNA came to me to ask what to do. The gifts started out small... she donated the clothes... Christmas was the cash gift... she felt like she would offend the family if she didn't accept the invitation to Easter dinner. A good chance no one would ever have known had the CNA not come to me for guidance.
As a Companion I was removed from a case and subsequently lost my job because a family fed me and an Alzheimers patient together. The client would eat better if she thought I was a friend and we were sharing a meal.
I'm suprised no one suggested notifying the BoN which is probably also appropriate ...sigh... No winners here. CNA has discipline against her license, agency loses a client and staff, client loses a compassionate and proficient caregiver.

Well at least she reported the situation to you, IMHO that would require serious education about appropriate boundaries(for client and family), how to politely and professionally decline, immediate removal from the case, and documentation of the counseling in the employee file. If the situation repeats then immediate termination with report to the certifying authority. In my state CNA's answer to the department of health and CHHA's answer to the BoN. If she has remorse and since she self reported counseling and education may be sufficient. Has she ever worked in a facility? My personal guidelines are if I wouldn't do this to/for/with my patient in a hospitals or other facility environment then I might want to reconsider doing it in the home. My refusal of inappropriate requests? I appreciate the offer but I cannot accept and keep my job. A letter of accolades to my agency/supervisor will mean so much more than a gift/cash/whatever. When I worked in the ER and a few happy patient families & patients wanted to send gifts and instead sent letters that I still have today more than a decade later.

tomc5555 · Apr 26, 2012

IMO the client or family sometimes initiates these boundary breeches. If this family and the caregiver are a good fit, you may want to educate them all and have all sign a contract.

That being said I always tell my client and families NEVER offer food, money or other gratuities to any caregiver. And I have refused such offers many times.

Good luck.

CabanaDay · May 1, 2012

I too believe the missing piece in all this is family member education. There is nothing in my agencies' home folders, or admit packets, educating the families about boundaries. At meet and greets with nursing management, where everyone sits around the room to see if I am a good fit for a case, not once has a nurse manager brought up boundaries to the family.

In fact it is quite the opposite: promotional material and website content portray stories of caregivers explicitly stating family members, "Treat me like family," and caregivers RPT, RN, OTR, Aide, no difference, all pictured embracing and smiling like family members.

This mixed message is then expected to be corrected by someone with very little education and training who was hired because of her compassion and caring and willingness to provide hands on care that the family, for whatever reasons, could not provide themselves.

Aides are set up to fail when it comes to boundaries.