Aides need context for training in ethics
Study shows need for more explanation
A study of ethical decision making by home health aides suggests they need more than a perfunctory reading of agency policies to help them handle issues that can arise in their work.
Aides might feel more prepared if they have the benefit of their instructors’ experiences and more thorough explanations of the meaning behind the rules, says Marcia Bosek, RN, DNSc (doctor of nursing science), an associate professor at Rush University in Chicago.
Bosek, a nurse ethicist, is in the midst of studying how health care professionals make ethical decisions. She asked home health aides to describe ethical situations they were involved in and how the situations were handled.
"They would tell stories, and my doctoral student and I would analyze those stories and came up with a process that they seemed to be using," she says.
Tough issues are the best
The stories ran the gamut of ethical quandaries that can face home health workers, including sexual advances by patients, patient abuse, and questions of billing fraud.
"They really didn’t feel like they’d been trained to handle them," Bosek says. "Some of them knew the policy. The quandary is how to interpret the policy. How close should you go? — things like that."
The biggest challenges didn’t seem to be the clear-cut black-and-white issues but those for which the course of action isn’t so easy to discern. As an example, she mentions a hypothetical situation in which an aide is asked to pick up lunch for a patient when she goes to a fast-food restaurant for her own lunch.
"You’re really not supposed to do extra things for people, but if they’re stopping for lunch on their way, it’s not out of the way to bring a sandwich," she says. "Should they do it? Some of it’s kind of that gray area. You have to figure out how far do you want to go."
Aides can have particular problems with ethical issues because of the nature of their job, she says. "Usually the nurse or the social worker is making the plan of care and the home health aide goes out and implements it," so they don’t understand the implications of any variance in the plan, she says. "They’re often in the home for longer periods of time; they’re doing more intimate care, so therefore they’re kind of set up for sexual advances and conflicts of planned care because they’re . . . there by themselves."
Prepare your employees
Bosek suggests two ways in which aides might be better prepared during their training.
1. Explain policies and the reason for them. One issue brought up in Bosek’s interviews with aides is a lack of understanding of agency policies and why they are important. Understanding the policies better can help aides navigate those gray areas that come up. An example is the common agency policy that employees shouldn’t give out personal information about themselves.
"You’re standing there and giving [a patient] baths Mondays, Wednesdays, and Fridays, and the patient will be telling you about her daughter and her grandchildren, and then she’ll say to you, Do you have children?’ or How are your children?’ Here I am, learning and seeing personal things about this person, but I’m not supposed to disclose anything personal about me. To the aides, it seems very awkward."
In explaining that policy, an instructor can go into the purpose behind it, whether it is to prevent stalking of employees or to focus aides on what their roles should be in the home. "Is there supposed to be a purpose behind their conversation when they’re doing their tasks?" Bosek says. "With a nurse, they would be talking about assessing their mental status and educating them, doing a whole bunch of therapeutic communication. But what’s the aide supposed to be doing when they’re doing the bath? Does it matter if their conversation is more social, or are they supposed to be therapeutic?"
Understanding the policy can help aides know where to draw the line in casual conversation. Maybe an aide can, for example, say that she has a daughter, but draw the line at discussing an argument that she might have had with her that morning.
Bosek suggests instructors discuss with aides where to draw the line. "What are the personal things that are kind of common knowledge that I can talk about? Where are the limits?"
2. Tell aides how others handle similar issues. The experiences of instructors and supervisors can be valuable in helping aides think about how they will handle ethical situations. Bosek told the story of one aide who continually was propositioned by a patient. Because the man was somewhat smaller and frailer than the aide, she wasn’t really worried about the possibility of assault.
"Was she afraid this guy was going to maul her? No. She knew that wasn’t going to happen," she says. "Her feeling was that he disrespected her."
The aide verbally fended the patient off for weeks, never seeking help. The problem was resolved only when the man was discharged from care.
Bosek says aides make a conscious decision about whether to ask for help dealing with an ethical problem. They may believe they should be able to take care of the problem themselves. Trainers can help by giving them tools to use in those situations before they ever happen, drawing on their own past experiences. They can say, "This is how I’ve handled this when it’s happened to me." They also can role-play to give aides possible responses to ethical questions.
"We do it with our kids all the time," Bosek points out. "We say, If somebody approaches you, what are you going to say?’ So what do you do if somebody approaches you in a threatening manner and you’re in the home? What do you do if someone makes advances to you?"
Bosek continues to interview members of the home health team about ethical decision making. She already has spoken with nurses and social workers and plans to interview therapists, as well.
She is focusing on the system of support for staff to learn whether lack of support by supervisors in dealing with ethical problems contributes to turnover in home health staff.
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