The boundaries of care
The boundaries of care

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The boundaries of care

1.7 Establishing boundaries

Activity 6 Managing the hidden culture

0 hours 15 minutes

Imagine now that you are Marie's manager and you decide to call in at the unit on your way back from a day out. You often drop in unannounced to make sure everything is OK and because it is the only chance you get to talk to some of the night staff. You walk in on the joke-telling incident and hear from the corridor what has been said. What do you do?

  1. Go in and join in the laughter.

  2. Go in and confront the staff – if so what exactly would you say?

  3. Turn around and pretend you didn't hear.

  4. Decide not to challenge the staff now but to put on some staff training at a later date.

Now write a paragraph saying why you decided to tackle it this way. What went through your mind? If you decided not to intervene, think about how much worse it would have to get before you did go in and say something.

Discussion

Well, managers clearly have a role to play in containing these aspects of the work: acknowledging difficult issues, setting agreed limits on how tasks should be approached, and helping individual staff to walk the tightrope of not being too cut off or too close to those they are working with. If Marie's manager joined in, or even initiated the joking, there would be no containment and nothing to stop things getting worse. It is up to the manager, or occasionally inspectors, to set out what is expected and then monitor whether staff keep within agreed boundaries.

Intimate care is an area in which boundaries are almost inevitably crossed but it is by no means the only area in which a spontaneous response can have unforeseen implications.

Now we look at a real-life attempt at establishing the boundaries of care relationships. Enfield Social Services (1996) has drawn up guidelines on professional boundaries for a wide range of staff including field social workers and those working in residential care. The guidelines attempt to set markers on a range of issues in professional relationships with children and adults. In particular they cover issues about:

  • not taking advantage of clients (e.g. in sexual or financial transactions)

  • disclosure of personal information within professional relationships

  • expressing affection in worker-client relationships.

Click on the player below to hear Vicky Golding of Enfield Social Services discuss their guidelines on professional boundaries

Download this audio clip.
Skip transcript: Guidelines on professional boundaries

Transcript: Guidelines on professional boundaries

HELEN MADDEN
This is Audio Cassette 5 for the course K100 - Understanding Health & Social Care and is linked to Block 5. The cassette is in five parts.
Part 1: Hilary Brown, from the K100 course team talks to Vicki Golding, Area Manager for Enfield Social Services, who manages a generic team of 50 people, working with both adults and children. She was responsible for developing Enfield’s Guidelines on Professional Boundaries. How did the need for the Guidelines arise?
VICKI
The need for them arose following two workers who were suspended in Enfield for alleged abuse and inappropriate behaviour towards young people. In both cases the disclosures emanated from young people known to my area team so I was heavily involved in what happened and we needed to give the young people and the workers involved a lot of support. And in both situations, which were completely separate, I wasn't sure if the abuse had been intended or whether it had arisen out of breaches of professional boundaries and which made it more likely for the abuse to occur.
So, for example, in both situations the workers had taken young people home with them and had also given them small gifts. And what I then thought was that, if we had a policy on professional boundaries, then workers would be clearer as to what was acceptable behaviour and what was unacceptable, because the relationship between a worker and a user is very different from that of friends and families. And it can lead to misunderstanding and confusion if worker and user aren't clear as to their respective roles.
Obviously it's difficult because in children’s homes, for example, it's not unusual for a member of staff to take a child home, say, if they have a birthday party for their own child and it can certainly happen with people with learning disabilities who are often very tactile and who might say to a worker, “Do you love me?” and I think that can then create a difficulty for the worker, who doesn’t want to sound rejecting and yet again, it’s so easy if you say “Yes I love you” and that can go over into other things.
In a residential home that it is a really nice homely atmosphere, they haven't got a family but, but their family, in a way, is in the home and yet at the same time it has to be different and it's the tension between the two.
HILARY
What's in the guidelines?
VICKI
We've got three categories. We've got, er, behaviour which is prohibited so a very obvious one is sexual relationships between staff and users and accepting as a client somebody who's a member of your own family. Swearing because it's believed that if you work for the Local Authority then you have to abide by certain code of conduct. Workers can’t receive legacies. Disclosing whether you've received personal therapy. For a worker to tell a user that they've had personal problems crosses a boundary in that they can then move to sharing with them common problems and that can create a risk.
There's also a section which is at the line manager's discretion and recorded. So it's not prohibited but where there is concern around so we're taking possible safeguards. Under this is lending money to a client because sometimes that does happen with people who come in to see us and giving a client a gift, for example, so you would actually discuss that with the manager and make sure it was recorded.
And then there's a section at worker's own discretion and this is where a worker can do what they wish, but it has to be recorded so this covers, for example, a worker receiving a small gift for themselves. Something like, say, a bunch of flowers, small box of chocolates would be acceptable but that would need to be recorded.
Expressing anger at a client because we think that sometimes that is OK but again that needs to be recorded. Hugging and shaking hands. This is also at the user’s discretion. Disclosing your marital status and disclosing your qualifications. Those are examples.
HILARY
Some people might think that a user is entitled to ask about the background of somebody who's working with them and that, in a way, these guidelines create an inequality between the user and the worker. Could you, could you comment on that and whether that's come up in your discussions?
VICKI
I think that's really difficult. We've tried to get a balance because certainly a user might ask questions and is entitled to know and it would be very wrong not to. Sort of basic things about a worker but it is actually crossing the boundary into other things, in particular, problems that the, er, worker might have had. An example is, something around divorce, separation. Is the worker not going into that from their point of view. But I do think it's very difficult, it's not cut and dried.
HILARY
Were there other areas of controversy once you issued the guidelines to staff?
VICKI
Yes, there were. Er disclosing sexual orientation which we'd put on the prohibited lists. One of the reasons that people were very concerned is they felt it was discriminatory because disclosing marital status is at a worker's own discretion and also there were some situations in which it could be useful. Somebody working with HIV to actually be able to say, if asked, “Yes, I'm gay.” So, it was actually very difficult making the decision on what to do about that and we had a meeting of senior managers and we actually disagreed on it and it went out for consultation and we've removed that from the prohibited list but we're actually adding a rider that where a worker decides to reveal personal information, they have got to exercise a professional judgement so that was sort of a way round it really.
HILARY
How have you used the guidelines since you brought them into operation? Have they helped with dealing with abuse cases or disciplinary proceedings?
VICKI
Yes, they have helped. Workers have said that they found them useful. There's always been a lot of discussion and workers have said it really does help to know what is acceptable even though sometimes it's difficult to abide by the boundaries.
They've also been used in a recent disciplinary, where a worker was alleged to have abused the clients and where there'd been various breaches in professional boundaries. And I think it was very helpful that this was in the policy. Also for the users involved, because one of them knew that it must be wrong to reveal that kind of information and said, “If you believe that, then perhaps you can believe other things that I'm telling you.”
HILARY
How have you disseminated the guidelines to professionals and to users?
VICKI
They were launched at a meeting of managers throughout Enfield in the beginning and then went out for consultation to all units.
There was a fair amount of controversy, depending on the setting that somebody worked in. For example, with older people, I think, whereas we started off saying that we didn't think it was right to, for a worker to hug or kiss anybody. When it actually went to the unions, they were very unhappy about that and they're actually saying it really was important sometimes to give the older person a kiss or a hug, and it would be wrong not to do so. So there were various areas which people questioned and I remember one was about, um, having a picture of your family in your room. And although many people accepted that this was right and you don't actually want to see a picture of the worker with her husband and their lovely children, others couldn't see what the harm was in that at all
Although it was fairly minor, we had a lot of debate on that.
HILARY
The professional role that you were getting at is is one which is quite anonymous?
VICKI
Yes, but at the same time, you actually want workers to be warm and be able to empathise and to be caring. But a worker is very different from somebody you know socially.
I think clarity is very important because I think there are certain things which a worker would know is wrong. If a user offers a worker a drink, a cup of coffee, that's fine, if they offer them a meal, that might not be fine. And if they ask them to come for dinner, say a dinner 8 party then, then what I'm saying, obviously to me, that obviously isn't on. But it's those sort of things. So we've actually covered social meetings and there’s only acceptable as part of a care plan but otherwise it's not on.
HILARY
What are the risks to users, do you think, of, of workers getting too close and blurring these boundaries?
VICKI
I think that users are often very vulnerable. That they can be needy and boundary-less themselves and are open to exploitation by a worker in a powerful position who sees similarities, identifies with the user and I think it's just, very easy for it to slip over into abuse and not necessarily because the worker intends abuse.
HILARY
How do workers present these boundary issues in their direct work with users?
VICKI
Situations arise and then they might want to say to a user, actually, “I can't do that” and I suppose situations occur where a user might want to disclose some kind of abuse to a worker which has happened but will say, “I'm telling you this as a friend, I don't want it to go any further”. And then the worker would have to point out that, although they care about the user, that it is a different role and they might well need to do something about what they're going to be told.
HILARY
These guidelines seek to prevent abuse from occurring in the first place, don't they, by protecting both workers and users and stopping breaches which have occurred unintentionally and perhaps unthinkingly?
VICKI
I think you're quite right, that it is to stop breaches which are, which are unintentional because people don't always realise. And it's also to stop abuse which is intended and obviously that's more difficult because it won't necessarily stop that abuse.
HILARY
So if we looked at abuse as being about a breach of boundaries, in a way your guidelines strengthen the boundaries and make it clearer that they have been crossed in abuse cases. Is that how you've used them in terms of disciplinaries?
VICKI
Yes, certainly, because they do clarify where a boundary has been breached. So it is a management tool. But also for protecting the worker, which is really important because workers are vulnerable and er don't always realise how they're leaving themselves open.
End transcript: Guidelines on professional boundaries
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Activity 7 Guidance on professional boundaries

0 hours 30 minutes

Listen to this audio clip now. You will hear Vicky Golding, an Area Manager for Enfield Social Services, describing why her department decided to develop these guidelines and talking about some of the controversial areas in the guidelines and what it means to be ‘professional’.

As you listen to the audio clip jot down anything you react strongly to.

Then look through at Enfield Social Services' guidelines on professional boundaries between staff and service users (click on the link below to access the file) and note which items you agree with and which you would not want to be bound by in your own situation. If you are on the receiving end of care, think about whether you would want this kind of ‘professional’ relationship with your carer or if you expect them to be more open and personal with you.

Click to view Enfield Social Services' guidelines on professional boundaries between staff and service users [Tip: hold Ctrl and click a link to open it in a new tab. (Hide tip)] .

Discussion

Enfield Social Services' guidelines grew out of two situations in which workers had ‘overstepped boundaries’ by taking individual children home, but they cover the more general issue of where to set limits in professional relationships in terms of how much personal disclosure and expression of affection is ever appropriate in a professional relationship. The model of professionalism represented here is one which errs on the side of maintaining a certain distance. Did you agree with this, or would you have drawn the line at a different point?

One of the controversial areas is just how much we expect workers to reveal of themselves. The Enfield Social Services guidelines suggest that workers should not reveal much about their personal lives to their clients but this can also create difficulties. For example, Marie told Richard about her boyfriend Barry as one way of re-establishing some distance when he was interpreting their relationship on a more personal level. Another exception might be that a gay worker at Marie's unit might be able to provide a very positive role model to gay or lesbian young people if they were allowed to be open about their sexuality. Vicky Golding drew a distinction between the kind of reciprocal sharing which goes on in a self-help group where one's personal experience would be seen as an asset in the work, and the more anonymous role of a care worker or social worker. Do you agree with this distinction?

Another difficult area addressed in the guidelines is the expression of affection and touch, which would be considered quite normal for children if they were being cared for within their families; kissing and hugging, saying ‘I love you’ and so on were also singled out as issues in services for older people and people with learning difficulties. It might be different for service users who get affection from other relationships in their lives than for people who are isolated and otherwise deprived of any such contact. What do you think? The guidelines also address the issue of favouritism; for example, if one resident is given gifts or taken out more than others in a group care setting.

Actions are ‘graded’ in the guidelines so that some are forbidden altogether, such as having sex with a client, others are subject to a manager's discretion and others are up to workers to decide for themselves. Did you find this helpful? Craft and Brown (1994) highlight the importance of guidance which works to ‘define the greatest possible leeway within which individual workers and teams can reach their own decisions’ (p. 18) and which balance these two functions:

… to draw some acceptable boundary around the personal and the professional and to define the boundaries within which individual workers can respond as they think best.

(Craft and Brown, 1994, p. 18)

The open consultation which has taken place in Enfield Social Services goes to the heart of what social and care services are about. Are social workers or care staff there to replicate ordinary relationships, to compensate for a lack of them, or to provide practical help while staying in the background so that people can ‘live their own lives’? Some clients may rely on professional carers to provide them with affection and social contact which they do not get elsewhere. The answer is bound to vary for different people and different settings, but the process of consulting with a wide range of people and attempting to provide some clarity is an important one for clients, staff and managers.

Vicky Golding emphasised that ‘professional boundaries’ are important for service users who:

are often very vulnerable – they can be needy and boundary-less themselves and open to exploitation by a worker in a powerful position …

But she also points out their usefulness as a framework for managers because they:

clarify what is acceptable and so where a boundary has been breached, we can actually point to it and use [the guidelines] as a management tool …

and for workers:

but they are also for protecting the worker, which is really important because workers are vulnerable and don't always realise how they're leaving themselves open.

This reflects the triangular nature of accountability.

Key points

  • Managers need to ‘contain’ difficult areas of care work.

  • Boundaries are not only crossed in intimate care but in ‘social’ settings as well.

  • Professional relationships are different from ordinary reciprocal friendships.

  • Formal guidance provides a reference point which can protect service users, staff and managers.

K100_8

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