I believe that most families are aware of one of their fundamental functions and mission—the protective function, which includes caring for weaker and dependent members. Providing care for one’s parents is one of the core moral and ethical requirements placed on adult children. These are requirements not only of natural moral law but also of God’s commandments—Honor your father and your mother, that your days may be long and your life prosper in the land that the Lord, your God, gives you (Dt 5,16) (cf. Sumec, 2005, p. 75). In this context, Pope Benedict XVI says: “With advances in medicine and other factors associated with increased longevity, it is important to recognize the growing number of older people as a blessing for society. Each generation can learn from the experiences and wisdom of the previous generation. In addition, ensuring care for older people should not be primarily seen as an act of generosity, but as repaying a debt of gratitude.” (Address by Benedict XVI to the elderly during his visit to St. Peter’s Residence on 18. 9. 2010)

For the preservation of dignity, freedom, autonomy and maintenance of a person’s basic self-care, it is certainly very good when a person in need can, where possible, remain in his or her own home environment. However, current social conditions place heavy demands on the workload of economically active individuals at the expense of family life. This fact also affects a family’s ability to care for its dependent relatives. The number of seniors living alone is increasing. Families, for various reasons, cannot, do not want to, or simply do not know how to provide this care themselves. As Academician Vladimír Pacovský (1990) emphasizes, the family must “want, know and be able.” If a family wants to responsibly care for its parents, it must create conditions for this care. Some can manage this on their own; in others, society should help within the provision of social services. An older person should mainly live and age in the family. Adult children should consider it their obligation to provide care for their parents. (Hechl, 1994, p. 33)

Not every family is able to care for its dependent member. This is where society, or community, should intervene, using various forms of social aid to help solve a situation that is very demanding and burdensome for families. P. Donati lists among social interventions that become reference points for the strategy of public social care the need for fair financial allocation, as well as fair distribution for those who voluntarily take on the burden of caring for children, older people and persons with disabilities, and the need for social interventions that fully take into account both the qualitative and quantitative needs of families. (cf. Sumec, 2005, pp. 58-59)

A concrete implementation of social help by society or community is the social service of caregiver care in the client’s home environment. Unlike social care institutions, this service is specific because it is carried out in the client’s home by a social worker—the caregiver. He or she comes to the client at an agreed time to help with self-care tasks, or contact with the social environment, which the client can no longer manage. The need for this service will certainly rise in the future given the increasing number of seniors and people who are dependent on the help of others.

What is caregiver service

Caregiver service is defined in legislation by Act No. 448/2008 on Social Services and the amendment and supplement to Act No. 455/1991 Coll. on self-employed activity (trade licensing act) as later amended. In this legal framework, §41 states that it is one of the social services provided to a natural person who is dependent on the help of another person, whose degree of dependency is at least Level II and who is dependent on help with self-care activities, household care activities and basic social activities. A specific feature of this service is that it is performed in the client’s home environment. Within this service, the caregiver helps with essential life activities of everyday personal hygiene, delivery and administration of meals, essential household tasks, and tasks related to running a household, as well as ensuring contact with the social environment.

According to §6 of Act No. 448/2008, providers of caregiver service must, in performing this form of social help, observe and keep primarily the client’s needs. The client has the right to receive a quality social service whose scope, form and mode of delivery allow the realization of basic human rights and freedoms, preserve human dignity, strengthen self-reliance, prevent social exclusion and support integration into society. These principles should be the basic ethical standard of every social service, including caregiver service. In addition, the provider of social service is obliged to consider the individual needs of the recipient, and to activate the recipient according to his or her abilities and possibilities. Furthermore, the law in §7 declares that social service should be provided on a professional level, in cooperation with the family, municipality and community in creating conditions for the return of a social service user from a full-year residential setting to a natural family or community environment, respecting their personal goals, needs, abilities and health status.

Ethical principles, responsibility and conduct of social workers in respecting the rights of recipients are defined not only by the Social Services Act but also by the Code of Ethics of Social Workers in the Slovak Republic from 1997. (This document is also published in Mátel et al., 2010, p. 68) “A major shift in this area was also the adoption of the Code of Ethics of the Association of Providers of Social Services in the Slovak Republic in Bratislava on 21.5.2009. This document was adopted for the needs of the Association of Providers of Social Services in the Slovak Republic, which currently registers 75 member organizations.” (Ďurčeková – Tekel, 2010, p. 323)

Specific ethical problems and dilemmas of home caregiver services

Every social service has its own specific ethical dilemmas and problems. Practical application of an ethical code is realized in the spirit of the concrete social service provided. “Clearly defined rules contained in professional codes not only point to the most important values to which a profession adheres, but also include requirements for the behavior of members of that profession. In this context, one can often encounter the view that professional ethical codes protect members of a professional community from errors or faulty practices that may occur in certain situations (J. Vajda, J., 2004; Thompson, M., 2004; Banks, S., 2001).” (Levická, 2010, p. 13)

Matoušek (2003, pp. 62-63) describes ethical principles as rules that regulate desirable professional behavior regarding difficult, and possibly conflicting, situations. Conflicting and difficult situations that require ethical decisions are also called ethical dilemmas or ethical problems. Sarah Banks (2006, p. 160) defines an ethical dilemma as a choice between two equally unwanted (undesirable) alternatives that complicates conflict between ethical values. “The nature of a dilemma is that whatever decision is made will have unforeseeable consequences. Usually there is a choice between two or more contested values or ethical principles that we believe are all important” (Banks, 2006, p. 169). In contrast, a practitioner and author (Banks, 2006, p. 169) characterizes an ethical problem as a lack of adequate resources needed to improve the client’s situation. (Ďurčeková – Tekel, 2010, p. 323)

From my own practical experience as a social worker–caregiver and from a survey in the non-profit organization Samaritán, n.o. Martin, which provides home caregiver care, we can point to these most frequent practical ethical issues and dilemmas:

  • The caregiver, willingly or unwillingly, enters in an intimate way not only into the client’s life but also into the life of the client’s family and household, of which he or she often becomes part. The caregiver is more vulnerable to dual or other unhealthy relationships. Ethical dilemma: to what extent may the caregiver enter the client’s personal life and family life? Is it within his or her competence to perform only the caregiver tasks contractually agreed, or, if needed, can he or she enter the client’s life more deeply?
  • During the performance of his or her work, the caregiver may witness family problems and conflicts and may even be pushed to enter these conflicts—for example, as a witness, the client may ask them for advice, to help resolve family problems, and so on. Ethical dilemma: to what extent, and whether at all, does the social worker–caregiver have competencies to enter these problems and to “substitute” the profession of social counselor or therapist.
  • The caregiver often spends long hours alone with the client, without direct cooperation with colleagues and without the supervision of line managers. For this reason, he or she must immediately address current, often serious, problems and situations without help from colleagues, especially sudden deterioration in health (psychological or physical), death of the client, or other circumstances. Ethical dilemma: can the caregiver, if needed, immediately assume the role of a doctor, psychiatrist, or other profession? Is he or she personally mature and professionally equipped to respond to such challenging situations?
  • A client’s home conditions are not always ideal for performing caregiver service, especially in the case of a client who is alone, socially dependent, or in an unfavorable social situation. The apartment or house is often not barrier-free; often health aids are missing, and the bed of a bedridden client is unsuitable both for the client and for the delivery of caregiver service. Household appliances (vacuum cleaner, iron, etc.) are often worn out, which worsens working conditions. The home may be neglected, endangering not only the client’s health but also that of the social worker. This occurs most often with clients living alone who can no longer secure their basic needs, or with families in an unfavorable social situation, or where a family fails to fulfill its basic functions, especially when the situation lasts long. Ethical dilemma: should caregiver service begin at all with such a client, and to what extent may a social worker first enter into resolving housing issues or unfavorable social conditions when the client needs caregiver service immediately.
  • The social worker is often confronted with time pressure. He or she must decide whether to focus in that moment on personal contact with the client (conversation, encouragement, listening, etc.) or perform tasks required under the service contract within the time allocated for caregiver service. The caregiver must then leave for the next client and arrive at the appointed time. Therefore, they may occasionally be forced to act with the client in a directive manner to complete all tasks in time, especially personal hygiene tasks. Ethical dilemma: prioritizing personal support of the client and helping ensure social contact—communication, meeting emotional needs of the client—or completing personal care tasks, shopping, and essential household work with less direct personal contact with the client, and to what extent both sets of client needs can be reconciled.
  • In performance of work tasks such as shopping, the caregiver handles the client’s cash independently. The caregiver is also present in the home where the client’s and the family’s property is located, which is especially demanding with clients who are mentally ill, distrustful or suspicious. Ethical dilemma: how to ensure essential household tasks and handling of cash so that the client’s autonomy and dignity are not compromised, while also protecting the social worker–caregiver from possible suspicion or even unjust accusations from the service user.
  • In performing his or her work, the caregiver can be pressured by the client or family to perform tasks beyond those contractually agreed, or tasks beyond the caregiver’s professional competences (e.g., social counseling, nursing procedures, dealing with authorities, household tasks beyond contract, etc.). Ethical dilemma: how to communicate to the client that the caregiver lacks professional competence for such tasks when the caregiver also sees that the requested client needs are unmet and no one else is available to meet them.
  • In the provision of caregiver service, different caregivers often rotate for one client. Although we believe caregivers are professionally well prepared, each caregiver is a different personality with different traits, experiences, and temperaments. Ethical dilemma: to what extent is it possible to satisfy a client’s wish for a caregiver who fits the client’s nature and expectations about how caregiver service should be performed and their needs met.
  • In professional activity the caregiver has little time to meet colleagues and exchange professional experiences because he or she usually works alone with the client. Information about the client is passed among caregivers through entries in daily logs or through the caregiver service coordinator. Ethical dilemma: how to ensure collegial cooperation and management of caregiver services so that the social worker–caregiver does not feel isolated and left alone in his or her own decisions, which is psychologically demanding and can also lead to burnout or other mental health problems.

These concrete situations and ethical dilemmas are perceived this way from the perspective of the social worker–caregiver. We have indicated only some of them. In day-to-day professional practice, there may be more, and they can be varied, just as varied as the target group of clients receiving home caregiver services. Their resolution depends on the individuality of each social worker, his or her professional and personal competencies, abilities, skills and experience, but also on how managers in organizations that provide caregiver services in public administration in municipalities and cities, as well as experts in such demanding and diverse field, approach the issue—social work scholars, experts in further education, and professionals in other fields that collaborate with social work.

Possible ways to resolve these ethical dilemmas

The specifics of a social worker’s work in providing caregiver services in a client’s home and possibilities for resolving its ethical dilemmas can be approached using a systematic method for resolving ethical problems outlined by Reamer (Mátel et al., 2010, p. 147):

  1. Identification of ethical problems, including social-work values and duties that are in conflict. In relation to the ethical conflicts and dilemmas mentioned above, it is very important for social workers–caregivers and clients to recognize and discuss these dilemmas. The client or client’s family should be informed in advance about the possibility of situations such as rotation of caregivers, about rights and responsibilities of social workers during performance of their profession for a cared-for family member, about the fact that the caregiver, although should of course have basic knowledge of client communication, psychology, social therapy and social counseling, is not competent for such performance and should recommend a qualified specialist for those tasks.
  2. Identification of the individuals, groups, or organizations that an ethical decision is likely to affect. In home caregiver service, ethical decisions primarily affect the client and the client’s family. In addition, they affect individuals and organizations that provide care for the client. This concerns, above all, deciding which professionally prepared individuals or organizations can help resolve the client’s social problems. It is necessary to define in advance the scope of social service, tasks and authority of the social worker so that the client has the greatest possible comfort, and his or her rights to dignity, self-determination and decision-making freedom are not compromised, while the social worker–caregiver has a clearer situation in case ethical dilemmas arise in daily practice and does not fear responsibility for decisions made within his or her competencies.
  3. Preliminary identification of all feasible courses of action and consequences for all participants, including potential benefits and risks for each. In this case this may include determining and communicating the model of care. It is necessary to consider whether permanent residential care might be more beneficial for the client for at least some time, or whether outpatient care, or a combination of caregiver service with residential social-care services, or care provided by the family itself is preferable. Here an ethical dilemma also appears when family members are exhausted by demanding care of their relative. They begin to consider residential care, while still wishing to keep their loved one in the home setting. They face the moral and ethical problem of whether to place their family member in a social-care institution. In this context, caregiver service is a particularly valuable social service. A caregiver can offer substantial support to the family by helping reduce the burden of demanding care that family members can no longer provide on their own, while the dependent family member remains in the home environment. Of course, each social case is individual. It depends on each client’s and family’s concrete situation. It is also a matter for the social counselor to weigh recommendations for the client and family.
  4. In this context this also concerns a thorough examination of the reasons for the advantages and disadvantages of each solution option, taking into account the ethical code and applicable legislation and ethical theories, principles and guidelines, practical theories and principles of social work, and personal values (including religion, culture, ethical values and political ideas). Current legislation does not always facilitate the application of ethical principles. Economic reasons are often a major issue, since not every client or family has financial possibilities to pay for caregiver service for as many hours as needed. This is also an ethical dilemma for organizations that provide this type of social service. They would like to meet legitimate client needs but must seek a compromise between those needs and the client’s financial possibilities. A social worker—thus also a caregiver—may face situations where, from his or her perspective, another action would be preferable than what legislation or internal organizational rules allow. In addition, each social worker is different and has a different hierarchy of values. Likewise, each client has a personal hierarchy of values and moral or ethical principles and ideas, which may sometimes conflict with the social worker’s ethical principles. The starting point is mutual communication and the client’s legitimate interests. The basic moral and ethical principles in the ethical code should be internalized and applied in practice by social workers, i.e., caregivers, as binding. In ethical dilemmas, the dilemma should be discussed among social workers, especially by beginner social workers with more experienced colleagues and, where appropriate, with other experts. Ethical dilemmas should be solved with the client’s needs, satisfaction of needs and welfare as the primary good. Of course, neither a social worker nor a caregiver can ever have absolute certainty that they acted in the client’s higher good.
  5. Consultation with colleagues and relevant experts (organization employees, supervisors, legal advisors and ethics experts). Here I see one of the most important possible ways to address ethical dilemmas in caregiver work. I believe that supervision, continuing education, and the possibility to consult with experts are still underused. In practice, supervision is especially important because the caregiver usually works alone in the client’s home and has no one immediately available to advise what is being done correctly and what should be done differently. In our experience, supervision is still used relatively little in caregiver practice. Supervision can be carried out by more experienced senior colleagues or by the caregiver service coordinator.
  6. Making the decision and documenting the whole decision-making process. Documentation in caregiver practice is carried out mainly through records of services provided in the client’s home after each visit. It primarily includes registering which caregiver tasks were performed and any changes in the client’s health condition. In caregiver practice, more written records should be used for decisions made by the social worker, counselor, municipal or district social department worker, labor office, social affairs and family office staff, or by the caregiver in their work. Such comprehensive records should be regularly reviewed and communicated by all involved social workers. This would certainly benefit the client, improve the quality of caregiver services, and above all provide a comprehensive set of services (not only caregiver service) that the client or family needs. Comparing and evaluating records from home caregiver service across clients would help caregivers in their work. They could compare situations they need to solve with similar situations from other clients and how they were addressed. If a solution proved unsuitable, the situation could be addressed differently; if it proved useful, that solution could be repeated with another client.

Conclusion

The provision of caregiver service in the client’s home environment is an established service and, we believe, also a promising and increasingly desired social service for the future. As we indicated in our contribution, caregiver service is highly demanding for the social worker who provides it. It has its own specific features, the most significant being the delivery of the service in the client’s home environment. It deals with a large number of diverse clients, families and situations. It involves ethical dilemmas and problems, some common to social workers in general and some specific to this field, as we indicated in the contribution. We proposed some ways to address this issue. We believe these can contribute to improving the work of social workers providing home caregiver service, particularly by improving their approach to the client, which is the central concern.

Author: Bc. Mgr. Iveta Gallová, PhD. Vysoká škola zdravotníctva a sociálnej práce, n.o. Bratislava

List of bibliographic references

[1] MÁTEL, Andrej a kol. 2010. Etika sociálnej práce. Bratislava: Vysoká škola zdravotníctva a sociálnej práce sv. Alžbety, 2010. 183 s. ISBN 978-80-89271-85-6. [2] SUMEC, Martin. 2005. Rodina a medzigeneračné vzťahy. Bratislava: Vydavateľstvo STU, 2005. 111 s. ISBN80-227-2212-X. [3] ĎURČEKOVÁ, Zuzana, TEKEL, Richard. 2010. Aplikácia etického kódexu pri výkone sociálnej práce v rámci aktivít neziskových organizácií poskytujúcich sociálne služby v meste Nitra. In KAPPL, M., SMUTEK, M., TRUHLÁŘOVÁ, Z.: Etika sociální práce. Sborník z konference VI. Hradecké dni sociální práce. Hradec Králové: Gaudeamus, Univerzita Hradec Králové, 2010, 486 s., ISBN 978-80-7435-037-5. [4] HECHL, Ján. 1994. Prichádza tretí vek. In: Rodina ako predmet vedy. Zborník príspevkov z medzinárodného sympózia, konaného v dňoch 12.-13. mája 1994. Bratislava: Medzinárodné stredisko pre štúdium rodiny, 1994, 142 s. [5] LEVICKÁ, Jana. 2010. Etické dilemy sociálnej práce. In: KAPPL, Miroslav, SMUTEK, Martin, TRUHLÁŘOVÁ, Zuzana: Etika sociální práce. Sborník z konf. VI. Hradecké dni sociální práce. Hradec Králové: Gaudeamus, Univerzita Hradec Králové, 2010, 489 s., ISBN 978-80-7435-037-5. [6] Tlačová kancelária Konferencie biskupov Slovenska: Príhovor Benedikta XVI. chorým počas návštevy Domu seniorov [online]. Bratislava: Tlačová kancelária Konferencie biskupov Slovenska, [2010] [cit. 2010-09-22]. Dostupný z WWW: http://www.tkkbs.sk/view.php?cisloclanku=20100919004 .

The lecture was delivered at the International Scientific Conference Applied ethics in social work and other helping professions, held on 20. – 21. October 2010 in Piešťany and was published in the proceedings of that conference: MÁTEL, A. – SCHAVEL, M. – MÜHLPACHR, P. – ROMAN, T. 2010. Aplikovaná etika v sociálne práci a ďalších pomáhajúcich profesiách. Zborník z medzinárodnej vedeckej konferencie. Bratislava : VŠZaSP sv. Alžbety. 413 s. ISBN 978-80-89271-89-4.