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boundary issues (4)

Where work and home life meet

Joe Reynolds considers the following scenario:
You have just completed a house purchase. When you next visit the property, you recognise the family that has moved in to the house next door. They have a child with severe learning difficulties, and have made several complaints to the NHS body you work for about the speech and language therapy service you provide to the child...
It hardly needs saying that buying a house and moving is a major life-event, in personal and emotional terms as well as practically and financially. Similarly, making a complaint - or being complained about - can cause great anxiety for families and professionals, regardless of whether the complaint is justified. This scenario brings together two stressful situations, where emotional responses can make it more difficult to maintain boundaries. The specific scenario where a new neighbour turns out to be a parent who has complained about our clinical work may be rare. It is however an extreme version of a much more common experience. Though they may not often be immediate neighbours, how often do we and a service user and their family live in the same community, and come into contact in non-work settings? We could be members of the same church, golf club, political party or amateur dramatics society. We could both be parents of children attending the same school or sports club. Or we could be colleagues in the NHS or other services. In any of these cases, the challenge is to maintain boundaries through clarity about roles, while not damaging the therapeutic relationship. Professionals tend to be very clear about this; away from work we are offduty, and not acting in a speech and language therapy role. Carers and service users often understand this in a social context, but some find it difficult to avoid asking for speech and language therapy advice or clarification. It is essential to have ways to avoid getting drawn into providing clinical advice in social and off-duty situations. At the same time, we remain bound by professional obligations to preserve confidentiality and to maintain high standards of personal conduct (HPC, 2008). We are therefore never completely out of role. Relations with neighbours may be cordial, but they are not necessarily friends in the deeper sense. There are practical benefits to good neighbourly relations, to do with security, local environmental problems or community networks, for example. But these can be quite consistent with clear boundaries, and most people are able to negotiate how far they want to become closer friends with their neighbours. Boundaries can however become much more complicated where there is a grievance or dispute. The substance of a complaint about NHS care can vary widely, and not all complaints are critical of clinicians or of service delivery. Many are about waiting lists, waiting times, why so BOUNDARY ISSUES EXPLAINED The Health Professions Council Standards of Conduct, Performance and Ethics (2008) require us to behave with honesty and integrity at all times (p.14). We are reminded that poor conduct outside of your professional life may still affect someones confidence in you and your profession (p.9). Arguably, our clinical conversations and research literature do not focus sufficiently on moral principles, but they at least touch on the ethics around issues such as prioritisation and evidence-based practice. In this new series we think through the sort of everyday events which although they receive much less attention also need to be on our ethical radar screen. little therapy time is provided to a particular facility, or dissatisfaction with the model of service provision. These matters are ultimately about commissioning decisions at a strategic level, and are not always amenable to simple resolution by the therapist or their manager. Some complainants are also struggling with their own grief and bereavement over the disability of their family member, which can colour the way they voice their dissatisfaction. These instances need not have any implications for continuing positive relations between family and therapist, though it is important to recognise if the complaint becomes an obstacle to progress in the therapeutic partnership. In a smaller number of cases, the complaint is about the speech and language therapists assessment or management. Here there is some scope for the complaint to be handled informally by local action. Many such instances are settled through further discussion, review meetings with other partners, or through a clinical second opinion. Service managers have to provide the right support to staff affected by complaints, as well as ensuring that lessons are learnt if necessary, and that complainants receive honest answers. The role of the Chief Executive in replying to formal complaints adds a further pressure on the people involved. These can be difficult processes for therapists. It is vital to take a professional approach, and to avoid personalising the disagreement. If we take the matter personally, it becomes difficult to return to the therapeutic partnership later on. Particular problems arise where families or service users themselves have strayed into personal comment in their complaints or in local discussions. Occasionally there is no prospect of restoring trust in the relationship, and the only option is to arrange for care to be transferred to another therapist. In any case, it is critical that therapists in this situation receive effective support from their manager and from the other staff dealing with the complaint. In the scenario we started with, there could be many reasons why the family have pursued their dispute. Relations between the therapist and the family may be quite open and positive, in which case the additional status as new neighbours should not be problematic. A comprehensive complaints procedure should include whatever mediation and conciliation is needed to allow therapy to continue in the future. Ideally, the complaint can be put behind us once it is resolved. Conversely, it may be difficult and complicated to establish the new relationship as neighbours, and for everyone to understand that this is distinct from the relationship in the clinical setting. It may be necessary to discuss the difference quite explicitly with the parents. They also need to understand that our obligation to maintain confidentiality extends to off-duty hours, and that we would never comment on or discuss anything about our service users and internal NHS matters such as complaints. This applies even when other neighbours and our own family may be aware that we are providing a clinical service to the child in question. It would be regrettable if the previous professional contacts were to prevent the establishment of neighbourly relations, especially when these need not go beyond day-to-day practical matters. Where work and home life meet in a particularly complex and distressing way, it is essential that our line manager is aware of the unusual pressures on professional boundaries. Non-managerial supervision from a suitably qualified and experienced person will also be useful to make it easier to see the situation as dispassionately as possible, and to continue SLTP effective care for the child. Dr Joe Reynolds is a retired member of the Royal College of Speech & Language Therapists, email
Reference Health Professions Council (2008) Standards of conduct, performance and ethics. Available at: http:// copyofSCPEJuly2008.pdf (Accessed: 26 January 2011).