Jef Smith looks at the boundaries to be set between professional and personal contact in social care.
Looking back on my own career in various areas of social care, I can remember a number of incidents where professional and personal aspects of relationships with clients became ambiguously close, if not confused. There was the occasion when a single mother I was interviewing in her home suddenly showed me a set of pornographic photos. She told me that they had been taken by a boyfriend, but I didn’t stop to work out whether they featured her personally. There were the occasions on which, over a period of some months, I used to take a teenage girl out for long car drives alone at weekends. This provided a treat for a deprived child and the opportunity for us to talk about her problems in an unthreatening environment. However, our unchaperoned hours together involved risks which would certainly not be recommended today. On a different front, I recall with some shame the embarrassment I felt — and, I fear, sometimes showed — when encountering people with various disabilities and communication difficulties.
Every care worker could make a similar list. Your feeling, and not quite hiding, an initial disgust at a service user’s incontinence; responding over-enthusiastically to an elderly person’s comparing you to their son or daughter; getting angry at someone who is unco-operative or aggressive or who simply fails to hear or understand what you are saying. All of these constitute understandable responses which come close to allowing the personal to overtake the professional.
Setting down the rules
For many professions, it is not wholly possible to set down firm rules concerning how practitioners should behave towards service users. In social care — not uniquely, since teachers, doctors, nurses and others face similar conflicts — we are required to use our own personalities as part of the therapeutic toolkit we bring to the job. Demonstrating empathy with someone in physical or psychological pain is part of the role; indeed, in many situations failing to do so would fall short of good practice. But there are also boundaries which must not be crossed, even if it is difficult to define exactly where they lie.
Various codes of practice have attempted this task, but they have generally fallen short of the sort of authoritative statements which would end all ambiguity. Prominent among these are the codes of conduct for social care workers and managers produced by the General Social Care Council (GSCC) 10 years ago.
These are two documents, usually presented together and very similar in content; one directed specifically at social care workers and the other at their employers. The former sets out the standards to which all practitioners must subscribe “as they go about their daily work”; the latter repeats much of that material with the addition of the manager’s responsibility for making their workers aware of what is required and enforcing appropriate behaviour through supervision and, where necessary, disciplinary action.
The codes have been widely distributed: the GSCC reports that it has distributed over two million copies, not only to people working in social care but also to colleagues, service users, carers and the general public in an attempt to make clear what consumers of social care have a right to expect of those delivering services.
When the codes were introduced, they were intended to be the first step to comprehensive registration of the care workforce, a process which would have bound everyone working in the sector to obligatory standards of professional conduct. For a variety of reasons, not least the complexity of registering such a diverse and numerous group of employees, the process stopped short at the listing of social workers, published in 2005.
For a registered worker, breaching the code can mean suspension or, for a serious offence, the withdrawal of the right to practise. It is anomalous that these sanctions are in place for only a small minority; social workers constitute probably no more than 10% of the total workforce. The commitment to register care staff, whose involvement with vulnerable service users is just as close as that practised by field social workers, has frequently been restated by the GSCC and by ministers of successive governments. However, bringing this task to fruition has been put back several times and now looks more distant than ever.
The GSCC itself currently faces closure. In July 2010, the Government announced that in England its functions are to be transferred to the Health Professions Council, a body which already regulates over 200,000 workers in 15 health professions and which is being renamed the Health and Care Professions Council (HCPC) in recognition of its widened role.
This move was prompted partly by criticisms of the GSCC’s functioning, partly by the wider need for public sector economies, and partly by a general drive to bring health and social service closer at all levels. However, following the similarly motivated integration of provider regulation under the umbrella of the Care Quality Commission (CQC), critics fear that expertise in the specific areas dealt with by social care workers will be lost in the merger or, at best, that social care’s concerns will be diluted by inclusion with the much more numerous health professionals with which the HCPC will be dealing.
Care workers might regard these developments as academic because the question of whether or not they are subject to statutory professional discipline does not affect their continuing obligations under the code of practice. Employers, whether in the statutory, private or voluntary sectors, are obliged to publicise and enforce good practice under the terms of their own registration with the CQC. This should be sufficient incentive for ensuring that all their workers abide by the codes of practice, which the GSCC has described as a “clear and consistent set of guidelines for any individual or employer working at any level in social care”.
The codes provide sound advice on how individuals should behave towards the very vulnerable people with whom they have daily dealings. The boundaries between the personal and professional are central to this guidance.
The codes have six sections. These deal with:
protecting the rights and promoting the interests of users and carers
establishing and maintaining trust and confidence
encouraging independence while protecting from harm
avoiding possibilities for harm to others
upholding trust in services generally
being accountable for the quality of one’s own work.
Although each heading is followed by a set of examples, the total effect is inevitably one of a series of precepts at a fairly high level of generality. No one could disagree with any of it, but it is of limited help in any particular situation. “You must not form inappropriate personal relationships with service users” is a typical instruction, to which one is inclined to respond, “Yes, but what exactly is inappropriate?”
Advice on professional boundaries
More detailed assistance comes in a recent GSCC publication on professional boundaries, a compendium of advice drawn from the experience of conduct hearings considering the behaviour of workers accused of breaking the code of practice.
Although this document again specifically relates to field social workers, its implications for others in social care are both clear and helpful. It makes the point at the outset, for example, that appropriate professional behaviour should not be seen only in the context of sexual matters — the cases which most frequently hit headlines — but includes anything which has a negative effect on care users or impacts adversely on the reputation of the service.
A key consideration, it argues, is the imbalance of power which characteristically exists between a worker and a service user. Consumers of services often have a limited range of choices and are severely distressed by their problems; on the other hand, workers gain intimate knowledge of the people they help and can make critical decisions about the resources to which their clients have access. This power can, however, be used positively, to the service user’s advantage. It should never be denied, far less exploited, by the worker.
Keeping relationships within limits
The relationship between a user and a worker can be misinterpreted, or even misused, by clients themselves and some clients may take initiatives which, if accepted or reciprocated, would certainly breach professional boundaries, eg offering presents. It is the practitioner’s responsibility to exercise the restraint which keeps the relationship within appropriate limits, but to do so in a way which does not involve a rough rebuff or a rejection.
An older person may want to be cuddled affectionately, but it is for the care worker to hold back when an embrace moves beyond a token of affection to approach a sexual contact. Some clients may become severely hostile, but workers must seek not to respond with corresponding aggression, for that way lies abuse.
Helpfully, the GSCC document suggests a series of questions which workers might ask themselves when faced with problematic situations. Is the relationship focused on the user’s wellbeing or on meeting the worker’s needs? Might the service user have misunderstood the relationship’s boundaries? If there are doubts in the worker’s mind, have they shared these with a colleague?
There is often a significant gap between both the past life experiences and the current situation of worker and service user. Age, disability and family relationships are significant elements in this separation, which should not be denied. Care staff do not know what it feels like to be very old or severely disabled, and often cannot even easily relate to a service user’s feelings of loneliness, depression or fear of death.
One of the most overused and untrue of statements is “I know how you feel”; it would usually be better to acknowledge that we do not know and that we need a client to tell us. By the same token, accounts of one’s own problems are rarely helpful, however similar they may sound to those troubling a service user. They usually have problems enough of their own without being burdened with those of others, however well this gesture of sharing is intended.
Transparency is central to distinguishing personal and professional relationships. A contact which can be described frankly to a manager or supervisor is unlikely to have crossed over into anything inappropriate. By contrast, reluctance to tell a colleague about an incident or relationship could well be a danger signal.
Last reviewed 12 June 2012