Ethical Considerations for Home Visiting

When it comes to ethical decisions, there are no answers, there are only decisions.
– Mel Gray and Jill Gibbons

A number of ethical issues and dilemmas can arise during home visits. The intimacy of an ongoing relationship in someone's home, with no other professionals present, can lead to confusing situations. Ethical dilemmas are gray areas where there is no legal mandate. These issues are best handled by having agency policies in place and through the creation of additional policies when new situations arise.

Supervisors should review applicable program policies and have open discussions with home visitors regarding their experiences during home visits. This information and support will help home visitors handle situations as they arise while sustaining their relationships with the family. (See Ethical Considerations for Home Visiting in the Home Visitor’s Online Handbook.)

Confidentiality

During an initial meeting, it is important to establish what information (if any) will be kept confidential between the home visitor and the family and what will be shared with others in the agency and under what circumstances. Home visitors must be very clear that they are required to report child abuse or neglect, including domestic violence or use of illegal drugs by anyone in the home. It is also important to discuss the agency's policy on keeping family health information confidential and only disclosing personally identifiable health information with written parental permission.

Professional Boundaries

The term “boundary” refers to the differences between a professional and personal relationship with someone. Boundaries are frequently discussed in home-based programs because the very nature of being in someone's home every week fosters an intimacy that can be like friendship. Reflective supervision can be extremely helpful as home visitors explore their relationship with individual families. However, setting boundaries is such a pervasive issue in home-based programs that staff and Policy Councils often establish guidelines.

Home visitors may become genuinely fond of a family, live in the same community, and disclose information on more of a friendship level than a professional one. In small communities, home visitors may have known the family all their lives or even be related to them, as happens in some very small, rural programs. Their behavior may be determined to some extent by their desire to be liked by the family. Your agency should consider the community it serves and set policies about self-disclosure or maintaining a professional role during home visits.

There may be times of crisis, such as when a family member needs transportation to an emergency room or when there is no food in the house and the food banks are closed, that will tempt home visitors to provide cash or services that are completely outside of their regular services. Again, your agency needs to develop protocols for these kinds of events.

Home visitors may also be tempted to give a family their private phone number. Your agency should have a policy on this point as well.

The family may invite the home visitor to dinner or a birthday party. Home visitors may run into families at school or community events or at the grocery store. Reflective supervision and agency policies can help home visitors know how to respond in these situations.

The blurring or crossing of professional and personal boundaries can also arise between a supervisor and a home visitor, as well as a supervisor and a family. It is important to acknowledge when boundaries have been compromised and to take action.

Here are some principles for establishing, maintaining, and repairing professional boundaries:

• Start with the standards. The HSPPS require staff to comply with program confidentiality policies, according to 45 CFR §1302.90(c)(iv).
• Understand the value and importance of professional boundaries. Professional boundaries protect the well-being of children, families, and staff. They define the work that staff and families or supervisors and home visitors do together, honor the differences in their roles, and preserve the objectivity of staff.
• Acknowledge that boundaries can be fuzzy. Although professional boundaries are vital, they are not always clear — to children, families, staff, or supervisors. Supervisors and home visitors have a responsibility to define boundaries. In relationship-based work, it can be challenging to recognize and maintain them.
• Start with the personal. Many people have trouble setting boundaries, even at home. Consider how you define and maintain boundaries in your personal life.
• Celebrate your profession. The supervisors and home visitors in Early Head Start programs are knowledgeable, skilled professionals. By setting and maintaining boundaries, you honor your expertise and the value of your work.
• Define roles early and often. The supervisor and home visitor in a program are colleagues and may be friends. Together, they need to articulate their professional boundaries.

Bridging Cultural Gaps

Many differences in values, beliefs, and customs may emerge when the home visitor and the family are from different cultures. Ideally, these differences lead to mutual learning, discussion, and negotiation with an eye toward a shared goal, such as supporting the child's learning. Some cultural differences, however, present ethical dilemmas.

A common example is the American emphasis on individual autonomy, which contradicts the other cultures’ emphasis on valuing the group over the individual. One culture's etiquette may require them to offer something to eat or drink — and that the guest accept. For example, an Early Head Start home visitor may bring a snack and use it to share nutrition information. The home visitor may resist accepting tea or coffee out of a concern for hot drinks near little children. These differences can be discussed, and home visiting services can be delivered in a culturally competent and respectful manner. Perhaps the home visitor could accept a glass of water instead.

An ongoing challenge for home visitors is how to address various cultural beliefs on the use of spanking as a discipline measure. There is increasing and overwhelming evidence that harsh emotional and physical discipline methods (e.g., verbal shaming, spanking) are harmful to children's social, emotional, and cognitive development. Although it may appear to work in the moment, it is not effective in teaching self-control in the long term. Home visitors must walk a delicate line as they develop a relationship with parents based on respect, including respect for a family's cultural beliefs, while sharing information on harsh punishment. This is a good topic for staff training and meetings. Home visitors may particularly benefit from opportunities to role-play this difficult topic.

Last Updated: September 15, 2022