A therapeutic relationship means creating a positive alliance, or relationship, with a patient. Establishing a therapeutic relationship with a patient takes time, practice, and skill. It is important for a HHA/PCA to take the time to establish a good working relationship with their patient. It will make all the difference in their ability to provide good care to their patient and for their patient to feel good about the care they receive.

The relationship between a HHA/PCA and their patient/family is different from the one they have with their own family or friends. The relationship they have with their own family and friends is reciprocal, or mutual, meaning both they and their family member share goals and work to meet each other’s needs. The relationship they have with their patients and their families is one where they focus on their patient’s needs, problems, and goals. While they may take on many roles with their patients and the patients may come to view the HHA/PCA as “family,” or as a “friend”, it is important to always remember that Home Health Aides/Personal Care Aides are there to care for them. The patients cannot work to help the HHA/PCA meet their own needs. This does not mean that Home Health Aides/Personal Care Aides are not friendly with their patients and their families. It just means that they must always focus on their patient and be aware of professional boundaries.

How to Establish a Therapeutic Relationship – Part 1

Trust

Especially during the first few interactions with a patient and their family, it is important for Home Health Aides/Personal Care Aides to demonstrate that they are trustworthy. This means showing up when they say they will, performing tasks and skills well, being honest, and demonstrating their concern for their patient’s well-being.

Setting Boundaries

When meeting a patient and their family, Home Health Aides/Personal Care Aides should let them know who they are and what their role is. Tell them the tasks they can and cannot perform. For instance, they can say something like, “I am Karen. I will be your HHA/PCA. If it is okay with you, I will be coming here Monday, Wednesday, and Friday to help you bathe, dress, and eat. I am also here to be a support to you and your family.” If a patient/family asks a HHA/PCA to perform a task they are either not trained to do, is outside of their scope of practice, or that they are uncomfortable with, let them know, and inform their supervisor. They can say something to the effect of, “I’m sorry, I am not able to put a catheter in you. I will let your nurse know that this is something you need help with.”

Confidentiality

It is important to let their patients know that they will protect their privacy. However, they should never tell a patient that they will keep something a secret, especially from their supervisor and the rest of the healthcare team. If a patient asks if they can tell their HHA/PCA a secret and that they not tell their nurse,they should politely let them know they cannot do this as their whole team is there to help care for them. They can say something like, “Mr. Thorpe, I cannot keep a secret from your nurse or doctor. They are here to help care for you. I do have to share what we do and talk about with my supervisor so that she knows you are properly being cared for. However, I will not share what you tell me with anyone outside of your health-care team if you do not wish.”

How to Establish a Therapeutic Relationship – Part 2

Empathy

Having empathy for another person means that you understand the thoughts and feelings of the other person. Empathy is different from sympathy. With sympathy, we feel sorry for another person. Home Health Aides/Personal Care Aides should be careful not to feel sorry for their patient as this often comes across as pity, or being condescending (looking down upon a person), which most people do not like. Sympathy is also more of an expression of one’s own feelings, while empathy shows one understands a patient’s feelings. In expressing sympathy, we are showing agreement with the other person instead of helping them explore their feelings. Demonstrating that they are empathetic, or understanding, of their patient’s thoughts and feelings shows their patient that they care for them and are there to help them. Here is an example of the difference between sympathy and empathy. In this scenario a patient has just told their HHA/PCA that they have been diagnosed with cancer.

Sympathetic response: “Oh! I am so sorry! That is terrible! I know exactly how you feel. My mother was diagnosed with cancer last year and it has been just awful.” You then go on to describe the situation with your mom and how upsetting it has been to deal with her diagnosis.

Empathetic response: “How upsetting this must be for you. When my mom was diagnosed with cancer last year I had so many different emotions. What are your thoughts and feelings about your diagnosis?” You then sit with the patient and allow them the time and space to explore their thoughts and feelings. Here, the focus is on the patient and not on you.

Positive regard

Positive regard is respecting another person and demonstrating that you value them as a person, regardless of your differences, and whether or not you agree with their thoughts, feelings, or behaviors. We demonstrate our positive regard for someone by our verbal and nonverbal communication. What we say, how we say it, and our body language all demonstrate our respect for another person. If a patient does something that the HHA/PCA does not approve of or says something that is in disagreement with their own beliefs, it is important for them to convey to the patient that they are not judging them. Home Health Aides/Personal Care Aides should watch their tone of voice, facial expressions, and body language. For example, a patient may tell a HHA/PCA that they have decided to stop receiving life-saving treatments. While they may not agree with their decision, they must convey an understanding of and respect for their decision. “Mr. Wahlman, that must have been a difficult decision for you to make. How are you feeling about it?” This response demonstrates that they respect their right to make a decision and are interested in understanding how they feel.

How to Establish a Therapeutic Relationship – Part 3

Over-Helping

Sometimes, we want to help others so much that we take away their independence. For HHAs/PCAs, it is important that they properly care for their patient and help them with what they cannot do for themselves. It is also equally important that they work to promote their independence so the patients do not become too reliant on the HHA/PCA and not do for themselves what they are capable. Promoting independence helps to boost a person’s self-esteem and helps to avoid feelings of helplessness and worthlessness. For instance a patient who is capable of cutting their food might say,“Can you cut this for me? I am too tired.” The response can be something like, “I understand that you are feeling tired today, but it is important that you do things for yourself that you are able. One of the goals we are working on together is to help you become independent and regain your strength. I will sit with you while you cut your food.” This reminds the patient of the established goals, provides encouragement for them, and demonstrates belief in their capabilities. It also demonstrates that the HHA/PCA will be there for them even when they must complete difficult or tiresome tasks.

Possessiveness

As Home Health Aides/Personal Care Aides develop strong working relationships with their patients and their families, they will come to know them very well. They may come to know them better than other members of the healthcare team. Sometimes, this can lead to feelings of possessiveness over the patient/family. They may feel that they know how to best treat their patient. This leads to a breakdown in the care of the patient among members of the healthcare team. It is important to be aware of these types of feelings. Examples of feelings, thoughts, and behaviors that may indicate possessiveness over a patient include:

• feeling angry toward other health-care team members when they make decisions that the HHA/PCA does not agree with
• arriving to work early and leaving late to spend extra time with the patient
• withholding information from other members of the health-care team
• excessively disclosing personal information about yourself to the patient/family to form a close relationship
• creating a “you and me against the world” attitude where the HHA/PCA views the patient as more than a patient and sides with their position regardless of the situation.

These types of feelings, thoughts, and behaviors are unhealthy for both the HHA/PCA and the patient. They only serve to create disconnection in the patient’s care and make the patient too reliant on the HHA/PCA. If a HHA/PCA finds that they are starting to become too possessive of their patient, they should speak with their supervisor about their feelings and how to work these out.

Terminating the Relationship

Different from your relationship with your own family or friends, there may be an end date to the relationship between a HHA/PCA and their patient and family. Some patients/families may want to continue to have a relationship with the HHA/PCA. They may ask them to call and visit. Ending a relationship with someone is often very difficult. It can awaken strong feelings in the patient and in the HHA/PCA. Patients may feel uncared for, angry, or depressed that they will no longer be working with the HHA/PCA. It is important for a HHA/PCA to remember to keep professional boundaries while also explaining to the patient how much they have enjoyed and have come to value the relationship you have with them. For example, a patient might say,“Will you come visit me even after you stop working here?” The HHA/PCA can say something like, “I have enjoyed working with you so much. I am not able to continue to come visit you once we have stopped working together. It is against my company’s policy. Let’s talk about how you feel about ending our relationship.” Ending a relationship with their patient may also stir up strong feelings for them. It is important for a HHA/PCA to discuss their feelings and how to handle them with their supervisor and not their patient. They must remember that they are there to care for the patient, not the other way around. The company may have specific policies about termination of relationships. This is an important issue to discuss with a supervisor.

It can be difficult to decide if a behavior is crossing the lines of professional boundaries. A helpful way to decide whether one should proceed with a behavior or not is to follow a decision tree.

REMEMBER: If a Home Health Aide/Personal Care Aide comes to the realization that the behavior is not part of the care plan, and is not in the best interests of the patient/family, they should not engage in the behavior. If they realize that the behavior is outside of their scope of practice and not within their defined role as a Home Health Aide/Personal Care Aide, they should refrain from the behavior. If they realize that the behavior is not something they would want others to know that they did, they should refrain from the behavior.

Self Check for Boundaries

Questions for self-reflection: Adapted from Jane W. Barton’s Professional Boundaries: Discerning the Line in the Sand

1. Is this behavior or action in my patient’s best interests?
2. Whose needs are being served by engaging in this behavior? Mine or the patient’s?
3. Are my actions meant to best meet the needs of my patient or am I meeting my own needs?
4. What emotions of my own are being stirred up by this patient/family and are these emotions affecting my ability to effectively make decisions and care for my patient?
5. Am I treating this patient differently than other patients with whom I work?
6. Will this behavior have an impact on the care I give my patient?
7. How would others (healthcare team members, patient’s family) view this?
8. Am I taking advantage of the patient?
9. Am I comfortable documenting this decision or behavior in the patient’s file?
10. Does this decision or behavior go against my agency’s policies?