Helping staff maintain therapeutic relationships
Helping staff maintain therapeutic relationships
Close supervision and careful scheduling
Maintaining therapeutic caregiver-client relationships can be a task in any home care situation, but with hourly as opposed to visit care, and client payment rather than third party reimbursement, it can be particularly challenging in private duty. Helping staff walk the line between providing personalized, compassionate care to clients in their homes and becoming personally involved and less professionally objective requires continual management oversight and sensitivity, sources say.
"Sometimes it's just human nature especially in long-term cases if a [caregiver] becomes [overly] involved. It may be filling a void in either the client or [caregiver's] life," says Margie Pence, RN, C, BSN, nurse manager of Private Duty Nursing for Mercy Home Health Care in Cedar Rapids, IA.
Renee Williams, RN, BSN, staff supervisor and educator at Caregiver's Community Health Services in LaPorte, IN, agrees. "It happens a lot in extended care. A patient admires a home health aide and it becomes an attraction. And the more time [spent together], the greater the [attachment]."
Subtle changes may signal problems
Recognizing potential problems requires discerning sometimes subtle signs and behavior changes in patients and caregivers, sources say. "You may hear emotions coming through when [the client or caregiver] talk about each other. The client may say'Oh I just love her to come here,' or they may call in the office and ask about [the caregiver] on their days off. Or the client is always choosing the person for personal things, for example, to go to a birthday party or other outings," says Williams.
Multiple schedule changes - requested by either the staff member or client - also may signal problems, says Pence. Client requests will usually involve scheduling one person more often. Staff scheduling changes may go either way, i.e., they may try to get more time on a case or schedule themselves off.
Staff may provide clues
Sometimes clues come indirectly through other staff. For example, the scheduler may report that a nurse said "I just need some time away," Williams notes. Or field staff members may make comments such as "It's so hard to follow Suzy because it's so hard to please Mrs. B.," says Pence. Chronically ill patients in particular may play one staff member against another to boost their self-esteem, she adds.
Sources, noting that prevention is the best approach, offered the following tips to help keep client-staff relationships in balance:
r Educate staff.
Educate staff about maintaining therapeutic relationships and the hazards that can otherwise occur, Pence suggests. "Try to protect staff confidentiality as much as possible," advises Terry Moffett, LPN, director of Private Duty Services at Quality Home Health Inc. in Morris, IL.
"Encourage them not to give the client their own or someone else's telephone number, and have them encourage clients to direct inquiries to the office," she adds.
r Closely supervise.
"Try to keep an eye out for problems. Listen to what the employee and patient are saying," Williams recommends. Go to staff when you receive subtle messages, she adds. "They may not want to go to you. They may look at it as a failure."
r Carefully schedule.
Closely managing work schedules may help forestall problems, sources say. "At the beginning, introduce enough caregivers so that the client is used to it, and don't [allow staff] to work too many days in a row," Pence suggests. However, she cautions against hard policies that limit the number of hours or days a week that staff members can work in a particular home. "Sometimes it works out fine for people to work 40 hours a week [with one client]," she notes.
r Reassign staff.
When clients and staff get too close, you may need to reassign the staff member. "Give both some time and distance," Williams advises. "Ask the [caregiver] whether they want to go back. Separate them for as long as it takes for them to be comfortable in that situation," she adds.
And "be honest with the client [about the situation]. Give them as much notice as possible, depending on the urgency of the employee. If the employee is in tears saying,'I just can't go back out again,' then you may have to make an immediate change. Otherwise, we try to give at least one week's notice and maintain the existing schedule [during that time]," says Williams.
When confronted with the loss of a favored caregiver, clients may be unhappy at best or angry at worst, sources report. Patients' private payment for care may confound their feelings and complicate the service dynamic. "It is the person's right to have the person or qualities they want," says Williams. Moffett agrees. "In private duty, the patients have the say if they don't want the person."
The client's natural response to the staffing change may be "then I don't want anybody," says Williams. But they may have that reaction only because they are accustomed to a particular caregiver. It may help to bring up examples of situations in which they would need help, she adds. If a patient continues to refuse or disqualify caregivers, openly discuss the situation, Moffett advises. "Tell them'we've done the best we can. We've gone through all our caregivers. You will have to accept this person or yougoing to have to provide the care yourself.'"
Still, if patients are unalterably opposed to allowing a different employee in their home, you may be forced to terminate services. "You can't jeopardize workers or put the company at risk. We have to do what's right for both the company and the client," says Williams.
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