Informed Consent

Dual Relations and Beyond: Understanding and Addressing Ethical Challenges for Rural Social Work Michael R. Daley, Ph.D. LCSW PIP, ACSW University of South Alabama [email protected]

Sam Hickman, ACSW West Virginia Chapter of NASW [email protected]

Journal of Social Work Values and Ethics, Volume 8, Number 1 (2011) Copyright 2011, White Hat Communications This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of White Hat Communications

Note: An earlier version of this paper was published in the proceedings of the 33rd Annual National Institute on Social Work and Human Services in Rural Areas in Boise, ID as: Daley, M. R. and Hickman, S. (2009, July). Navigating the ethical landscape of rural practice. In Rodenheiser, R. W (Ed.) Proceedings form the 33 rd Annual National Institute on Social Work and Human Services in Rural Areas, (pp. 35-57). Boise, ID: Boise State University.

Abstract

Several authors have identified the special nature of ethical challenges faced by social workers who practice in rural areas. The authors discuss specific areas of ethical risk for rural social work such as dual relationships, confidentiality, anonymity & self-disclosure, and competence. Appropriate strategies for strengthening ethical practice and minimizing ethical risk are presented.

1. Introduction

For many years social workers who practice in rural settings have been aware that a heightened sensitivity to some sections of NASW’s Code of Ethics (2008) is essential for maintaining ethical practice. Rural communities provide an environment in which the social worker is deeply involved in the community, professional expertise or supervision may not be present, individual social workers are

widely known, confidentiality may be difficult to maintain, and relationships may be both complex and multiple (Burkemper, 2005; Daley and Avant 1999; Ginsberg, 1998; Ginsberg, 2005; Gumpert & Black, 2005; Miller, 1998; NASW, 2006). These ethical themes are also consistent with those raised by Green, (2003) with regard to rural social workers in Australia, and those identified for rural psychologists (Helbok, Marinelli, & Walls, 2006). The context of rural practice presents increased

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ethical risks for rural social workers and requires advanced understanding of ethical responsibility and a need to strengthen and emphasize ethics training for rural practice (Daley & Doughty, 2006; NASW 2006).

Although rural social workers have generally understood the importance of ethical risks they face for some time, increased attention has been paid to the ethics of rural practice since the early 1990s. Miller (1998) indicates that the 1993 revision to the NASW Code of Ethics that included principles on nonsexual dual relationships stimulated controversy because of the difficulty in avoiding these types of relationships in rural social work. The potential vulnerability and heightened risk for rural social workers that this revision highlighted mobilized the Rural Social Work Caucus to affect a change in the wording of the dual relationship standard in 1996 to better reflect the realities of rural practice.

The social work profession’s experience with the Code of Ethics during the 1990’s generated an increased level of interest in ethical practices among rural social workers and has subsequently led to a growing body of literature on the subject. This article draws on the conceptual and empirical work that has been done on ethics for rural social workers over the last twelve years to review the major ethical issues that have been identified and suggest some strategies that may be used to strengthen ethical practice. Indeed the purpose of this article is to provide a review of prior work that coalesces current thinking on rural social work ethics that may prove useful to rural social workers and social work educators alike.

2. Ethical Issues for Rural Practice

The Code of Ethics of the National Association of Social Workers (2008) is generally the accepted standard for ethical conduct for professional social work. NASW has 150,000 members and is the largest social work organization in the world (NASW, n.d.). Each member of NASW is required to adhere to the Code of Ethics as a guide to professional conduct (NASW, 2008) and the Council on Social Work Education identifies this code as the basis for teaching values and ethics in social work curricula (CSWE, 2003). Furthermore, almost one-half of the states reference the Code in regulating social worker behavior through their licensing regulations (Morgan & Carvino, 2006) and though not directly referenced, many more state regulations are strongly influenced by the Code.

The Code of Ethics identifies general principles that apply to social workers in all types of settings. While specific principles in this code appear to present special challenges in application for rural social work, there is general agreement that these challenges are not sufficient to define a separate code of ethics for practice in rural communities (Boisen & Bosh, 2005; Daley & Doughty, 2006). As Ginsberg (2005) indicates, “social work with rural populations and in rural areas is, ideally, simply good social work that reflects and considers the environment in which practice takes place.”

It is in the reflection on and consideration of the rural environment that social workers need to be knowledgeable in order to maintain a high standard of practice. The growing body of literature on rural ethics has called for the profession to focus on this interface between the practice environment and the Code (Burkemper, 2005; Daley & Doughty, 2006; Strom-

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Gottfried, 2005). Consequently, the specific areas of the Code that may prove more challenging for rural social workers are an important topic for further discussion.

3. Ethical Challenges: A Review of the Literature

The early discussions about ethical challenges for rural social work focused around the difficulty in avoiding dual relationships. More recently consideration has been given to additional areas of the NASW Code of Ethics where practitioners in rural areas may face ethical risks. The following section outlines the areas of ethical concern most appropriate for the rural environment including dual relationships, poor practice and competence, confidentiality, anonymity and self disclosure, and colleague related issues. 4. Dual Relationships

Undoubtedly, the dual relationship is an ethical principle that has received the greatest attention in rural social work (Boisen & Bosch, 2005; Burkemper, 2005; Daley & Doughty, 2006; Galambos, Watt, Anderson, & Danis, 2005; Galbreath, 2005; Green, 2003; Gumpert & Black, 2005; Miller, 1998; Strom-Gottfried, 2005; Watkins, 2004). Helbok, Marinelli, & Walls (2006) also identify multiple relationships as a potential area of concern for psychologists who practice in rural communities. Ethical issues of this type fall under the general category of boundary violations that include both sexual and non-sexual relationships between social workers and clients (Strom-Gottfried, 2000). But it is the non-sexual dual relationship that is the primary area of focus for boundary violations in the rural

literature. Sexual relationships are a specific type of dual relationship that is generally considered separately from dual relationships, likely because of the strong prohibitions against sexual contact in the Code and the perception that there are no circumstances in rural social work in which sexual relationships could be appropriately managed.

Dual relationships with clients are addressed in the Code of Ethics in sections 1.06 (a), 106 (b), and 106 (c) (NASW, 2008) and generally consist of social, family, or business relationships and exchanges in which there is potential for harm or exploitation of the client (Galbreath, 2005; Strom-Gottfried, 2000). Exchanges with clients involving barter also create the risk of exploitation and dual relationships (Strom-Gottfried, 2000) and are addressed in section 1.13 (b) of the Code (NASW, 2008).

This is an appropriate area of concern for rural social work. In a study of ethical violations reported to a social work licensing agency in a large state, Daley and Doughty (2006) report that boundary violations for rural social workers are alleged in nineteen and one-half percent of the reports. Allegations of boundary violations ranked second only to poor practice in frequency, although reports of boundary violations for rural social workers were slightly lower than those for social workers in urban practice. Fifty- two percent of the boundary violations for rural practitioners were for dual relationships (Daley & Doughty, 2006).

Examples of dual relationships include inviting clients to family or social functions like weddings or dinners. They also include transacting business with clients or their close relatives.

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Relationships of this type may easily create confusion about the nature of the worker- client interaction and in which actions the social worker is fulfilling the professional role. When confusion about the professional relationship between worker and client occurs, there is increased potential for either harm or exploitation of the client. Bartering becomes problematic in the sense that it is often difficult to establish fair value in the exchange. It is much easier to assess good, fair, or bad value when the unit of exchange is monetary and the use of money is impersonal. Barter or a swap for tangible goods or services creates greater difficulties in either fair value or impersonality. Thus when barter is used, there is potential for exploitation and role confusion.

While the Code of Ethics does not prohibit either dual relationships or barter, it does place full responsibility on the social worker to prevent harm to clients (NASW, 2008) and the real challenge for the social worker in rural practice is how to manage the dual relationships that may not be avoidable. Martinez-Brawley (2000) points out rural communities do not permit the distance to develop the impersonality that may be common to social work in urban areas, and Reamer (1998) uses small or rural communities as examples of contexts in which dual or multiple relationships may be difficult to avoid. Rural social workers must relate to others in the community in fairly close terms, thereby making it more difficult for rural social workers to avoid dual relationships, presenting challenges for maintaining ethical practice. 5. Poor Practice and Competence

Poor practice and/or competence of social workers are ethical concerns for rural social work that have been raised in the literature by several authors (Burkemper, 2005; Croxton, Jayratne, & Mattison, 2002; Daley & Doughty 2006; Strom- Gottfried, 2005). Poor practice refers to failures in meeting accepted standards for clients in areas like evaluation of progress, appropriate use of supervision, and making appropriate referrals. Some may use different terminology and refer to this as a competence issue, but in a general sense, both poor practice and competence refer to either significant substandard performance by the social worker or lack of adequate preparation for the method used.

Poor practice may be an especially significant area of ethical risk. Daley & Doughy (2006), in their study of reports of ethical violations, identify poor practice as the area of greatest difference between rural and urban social workers. In this study, poor practice comprised 27.1% of the ethical complaints against rural social workers. Strom-Gottfried (2000) also found that thirty-eight percent of the NASW ethics violations in her study were for poor practice, most frequently the failure to use accepted treatment methods. For example, behaviors included in this category were misapplication of self- determination or boundaries, using techniques inappropriate to the age or condition of the client, misusing skills by yelling at or using derogatory language with a client, inappropriate termination or transfer procedures including premature termination, lacking insight or empathy for the effects of worker behavior on the client, failure to make appropriate referrals or case transfers, prolong care beyond what was needed, and failure to seek consultation and informed consent (Strom- Gottfried, 2000).

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Poor social work practice is not an ethical violation per se, but when methods are used that violate generally accepted standards of practice, that do not conform to methods used by the profession, and where social workers lack appropriate training in the method or do not use supervision when needed, ethical violations may result. These are particularly thorny issues for rural social workers. Burkemper (2005), Croxton, Jayratne, & Mattison (2002), and Ginsberg (1998) all point to the independence in practice, broadened responsibilities, and the difficulties in obtaining supervision and continuing education in rural social work. Daley & Avant (1999) add that the rural social work labor force tends to have higher percentages of BSW educated workers and fewer MSWs with advanced credentials than in urban settings. All of this may result in social workers who are placed in situations for which they are not adequately prepared and appropriate supervision is not available (Daley & Doughty, 2006). The difficult dilemma they then face is to provide what service they can or to provide none at all (Croxton, Jayratne, & Mattison, 2002). Given these circumstances, it is small wonder that the rural social worker is at greater ethical risk for poor practice issues.

6. Confidentiality

Rural communities are often small communities with close relationships and exchanges between members. People and their cars are readily recognized, and their relationships and business tend to be widely known (Carlton-LaNey, Edwards, & Reid, 1999). In these circumstances it is often difficult to keep things confidential, as when a client is experiencing martial problems, dealing with a substance abuse problem (Ginsberg, 1998) or even

something as trivial as where one went to lunch or with whom.

Given the close and personal nature of interactions in small communities, it is not surprising that a number of authors have identified potential difficulties for rural social workers in maintaining client confidentiality (Burkemper, 2005; Daley & Doughty, 2006; Galambos, Watt, Anderson, & Danis, 2005; Green, 2003; Gumpert & Black, 2005; Strom-Gottfried, 2005). Helbok, Marinelli, & Walls (2006) also raise confidentiality as a concern for rural psychologists. Confidentiality is addressed in section 1.07 of the Code of Ethics, and maintaining confidentiality is a complex issue requiring sophisticated practice judgments by the social worker.

The primary concern for rural social work appears to be how the professional maintains confidentiality in this challenging environment in a way that is viewed as appropriate by both the social work profession and the rural community. Daley and Doughty (2006) suggest that rural social workers may already be finding ways to manage confidentiality appropriately. In their study they found that ten percent of the ethics complaints against rural social workers were for confidentiality violations and that this percentage was only slightly higher than that for urban social workers. Other authors identify strategies that rural social workers may be using to manage confidentiality effectively.

Burkemper (2005) and Strom-Gottfried (2005) indicate that the use of informed consent may help to reduce the risk of confidentiality violations in rural practice. Strom-Gottfried (2005) adds that explicit understandings with family and clients about how to manage information may also

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help to minimize ethical risk. Gumpert and Black (2005) discuss the application of a culturally sensitive approach for rural practice as an alternative to a strict rule based interpretation of the Code of Ethics. The culturally sensitive approach that they found used by a significant percentage of the social workers in their survey involved the use of boundary crossing but not violations to effectively work with their clients and local agencies. One example of this is for the social worker to acknowledge information already existent through the community grape vine while not violating client confidentiality as way of establishing working relationships in the community and with community agencies.

7. Anonymity and Self-Disclosure

Strom-Gottfried (2005) identifies the tension generated between maintaining the impersonal professional self and the need to gain acceptance within the rural community in order to be effective. Both Ginsberg (1998) and Martinez-Brawley (2000) explain this in terms of the need for rural social workers to adapt to the norms of personal relationships in the rural community to gain the necessary acceptance to practice effectively. In the rural community there is an expectation that social workers be known as people in order to fit in to the community, because formal professional credentials are not as readily accepted as in urban practice. Failure to become known personally may result in a perception that the rural social worker some how feels better or superior to others. Once community members view the social worker in this way, it is likely that the level of cooperation will be limited, possibly affecting the social worker’s effectiveness.

Unfortunately, personal disclosure is a double edged-sword for the social worker. Revealing too much or the wrong kind of information may also reduce the social worker’s efficacy. For example, when the social worker is seen as too different from the norm or as having too many personal issues of her or his own, community members may question the professional’s ability to understand their needs or provide help. In addition, when rural social workers need to seek help for personal or family needs, or exhibits some personal weakness (Green, 2003) this is often widely known because of the lack of anonymity within the community. Knowing this, a rural social worker may be reluctant to seek the help that is needed in order to maintain an image of professional competency. The result may be a conflict with the ethical provision of the Code (section 4.05 (b)) that requires social workers to seek help when problems or difficulties interfere with their performance and judgment (NASW, 2008; Strom- Gottfried, 2005).

Once again the primary issue is not so much that these ethical challenges exist, but how to manage these challenges. If the social worker is not open enough, it potentially raises issues with either competence (Code section 4.01) or misrepresentation (Code section 4.06). But when the social worker is too open with self-disclosure, this may raise the question of private conduct versus professional conduct (Code section 4.03) or affect the worker’s level of competence (Code section 4.01). Similarly, familiarity with those in the community may inhibit the social worker from seeking help for personal or family problems lest such help seeking be widely known. Yet there is a clear responsibility for social workers to seek help when personal problems interfere

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with the performance of their professional duties. Clear identification of these ethical dilemmas, assessment of the relative risks, and prudent action to manage these ethical dilemmas are clearly an important part of the rural social worker’s repertoire.

8. Ethical Issues with Colleagues

While the complex, multiple, and overlapping relationships between social workers and clients in the rural community is frequently discussed, relatively little attention has been paid to the effects that the same kinds of relationships have on ethical practice with professional colleagues. As Martinez-Brawley (2000) indicates, close and personal relationships are necessary for survival in the rural community, but these relationships create a potential for ethical conflict between professionals in working with clients.

Green (2003, p. 217) also points out that because of the relationships that rural social workers have with other members of the community the ability to develop trusting and open relationships with their supervisors may be compromised. This may be due to the fact that in a close knit rural community the worker has friends or relatives who have other kinds of connections with the supervisor and this may affect the worker’s ability to discuss sensitive material openly.

Provisions of the NASW Code of Ethics that address social workers’ ethical responsibility to colleagues and practice setting responsibilities are found in Sections 2 and 3 of the Code. These sections emphasize the ethical obligation of the social worker to act in a professionally responsible manner. The Code is not prescriptive in this regard as it contains few dos and don’ts and leaves

considerable discretion to the social worker in managing potentially troublesome situations.

For the social worker in rural practice, this presents numerous ethical challenges. For example, section 2.01 (b) of the Code indicates that unwarranted negative criticism of colleagues should be avoided. While this may sound relatively easy to do, the lack of social distance and an overlapping network of relationships in a rural environment present numerous avenues in which a communication about a colleague may reach her/him directly or indirectly. As a result, rural social workers must be exceedingly careful about what they communicate about a colleague and think through the networks and avenues through which information may travel in order to minimize potential problems. Similar issues arise regarding the maintaining of confidential information shared by colleagues particularly in the course of seeking peer consultation (Code section 2.02). Given how easy it is for information to get back to people, and the overlapping personal, professional, and social relationships in the rural community, social workers must also be judicious in managing confidential information from colleagues.

Another area of concern for practice is section 2.11 of the Code. This section deals with the ethical obligation for social workers to address the ethical conduct of colleagues, seek resolution, provide assistance, and take appropriate action through formal channels (NASW, 2008). This aspect of ethical responsibility is an important aspect of the social work profession’s efforts to improve the quality of practice and regulate incompetent or unscrupulous individuals. However, in the close knit rural community, social workers

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usually understand that complying with expected behavior regarding the unethical conduct of colleagues may carry unpleasant consequences. These consequences may range from being placed in the uncomfortable position of having to see or interact with the offending social worker at work or in other social settings on a regular basis to attempts at retaliation through the local community or ethical counter complaints for lack of proper professional respect. Awareness of possible repercussions can make the rural social worker pause to think, to be reluctant, or even to fail to act.

Similar issues may arise in a rural community regarding social workers who have responsibility for evaluating the performance of others or who serve as administrators (sections 3.01 (d), 3.03 and 3.07 of the Code). Evaluations that are perceived in a less than positive light may be subject to negative reactions from subordinates that invoke community rather than agency networks. Administrators may be reluctant to advocate too hard for client groups or to push for additional resources for fear of angering powerful factions in the community. 9. Dodging the Ethical Traps and Strengthening Rural Practice There appears to be consensus that characteristics of the social and professional networks in a rural community can create special ethical challenges for the social worker (Daley & Doughty, 2006; Galbreath, 2005; Ginsberg, 2005; Martinez-Brawley, 2000; NASW, 2006). Multiple types of relationships and increased client contacts in arenas outside of work are examples of factors that may increase risk in rural practice (Boisen and Bosh, 2005). But as Daley and Doughty

(2006) argue, rural social workers appear to be finding a way to handle many of these challenges at least as well as their urban counterparts. So what kind of framework and practical guidelines may the social worker employ to avoid the ethical minefields of work in the small community and strengthen the quality of practice?

There are several frameworks for ethical decision making presented in the social work literature. Examples include models developed by Congress’s (1997); Dolgoff, Loewenberg, and Harrington (2005); Reamer, (2006); and Strom-Gottfried. All of these models present an ethical screening mechanism assessing benefits and risks for the social worker and the client in terms of professional service delivery. These models present questions and criteria useful to the social worker for evaluating ethical issues in the course of practice. For example Strom-Gottfried (2007) suggests asking questions like “Who will be helpful?, and “Why am I selecting a particular course of action?”, whereas Dolgoff, Loewenberg, and Harrington (2005) suggest “To what extent will alternative actions be efficient, effective, and ethical?” and “Which alternative action will result in your doing the least harm possible?” The important question to be raised is to what extent these models and even part of the Code of Ethics are relevant for the context of rural practice.

We would argue that the Current NASW Code of Ethics is broad enough and the existing frameworks are sufficiently inclusive for effective use in the rural context. However, it is in the application of the Code of Ethics and ethical decision making models that the social worker needs to be especially attentive to provide

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both appropriate and ethically based services. In their research Boisen and Bosch (2005) found that rural social workers were not using a separate code of ethics with respect to dual relationships, and Daley and Doughty (2006) found that rural social workers were managing ethical dilemmas at least as well as their urban counterparts. Both of these findings speak effective use of the current code by social workers in rural settings.

This should not be interpreted as meaning that in social work ethics one size fits all, especially with regard to rural practice. Clearly, given the literature on the subject, there are higher risks in some areas of the Code for rural social workers. Rather, it appears that it is in an overall perspective for applying and interpreting the Code that rural social workers should be especially attentive.

Gumpert and Black (2005) indicate that rural social workers appear more likely to use a relativistic or culturally sensitive, rather than a rule based approach in resolving ethical dilemmas. The culturally sensitive approach is similar to what Dolgoff, Loewenberg, and Harrington (2005, pp. 42) identified as ethical relativism in which ethical decisions are made based on either the context or the consequences that could result. Whereas the rule based approach is similar to the concept of ethical absolutism Dolgoff, Loewenberg, and Harrington (2005). The rule based approach tends to result in the social worker applying a stricter, more literal interpretation of the Code.

A culturally sensitive or relativistic approach to ethics appears reasonable for rural practice because it allows the social worker to make ethical decisions within the context of the rural community, whereas

the more conservative rule based approach may be much more limiting or even counterproductive. For example, the social worker accepting goods or services from clients is discouraged by the Code of Ethics, yet it is common practice in rural communities for people to share produce and homemade products such as jelly with others. Refusal by the social worker to accept such gifts in small quantities may be considered offensive and rude, and could even affect the worker client relationship negatively. Technically this accepting the gift is a boundary crossing, but is generally not a boundary violation (Galbreath, 2005).

The authors suggest that it is appropriate for rural social workers to use a culturally sensitive approach in the interpretation of ethical behavior and in the application of decision making models. This permits the social worker to adapt appropriate ethical practices within the norms of the community and region and to work more effectively. Likely this will lead to some boundary crossings, where clients can still be protected by appropriate safeguards, but exploitation and harm resulting in ethical violations could still be avoided.

Thus, the rural social worker will need to add a culturally sensitive perspective as an overlay to any framework used for application of the Code of Ethics. This kind of approach is suggested by Gumpert and Black (2005) and in order to do this effectively it requires social workers to develop a deep understanding of their community context, history, traditions, and culture (Daley and Avant, 2004) . Given this overall approach, there are some specific steps that social workers can use to more effectively manage any potential ethical issues they identify.

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10. Identify Potential Ethical Conflicts

Quite simply, ethical risks are hard to manage unless the social worker is aware that practice situations should be assessed in ethical terms, and ethical issues must first be identified as such (Burkemper, 2005; Reamer, 2006). In order to do this, the social worker must have a good working knowledge of the NASW Code of Ethics (Gumpert & Black, 2005). As discussed earlier, this knowledge should not be limited to the section that deals with worker-client relationships.

The social worker must then apply the principles outlined in the Code on a regular basis to all practice interactions. As the social worker develops experience operating in accordance with the Code, ethical behavior should become an integral part of practice. But some situations will raise questions, specific actions, or situations and will raise the question of whether or not this is an ethical issue. Prudence would dictate that a rational or reasonable personal standard be used. In other words, if this kind of question is raised, the situation or action should be treated as an ethical question, and it bears further investigation. Once the social worker reaches the conclusion that a potential ethical problem exists, effective management of the problem is imperative. So what are the best strategies for the rural social worker in managing this type of problem? Several strategies may apply including collecting more information, analyzing the situation further, or seeking consultation from professional peers or supervisors.

11. Seek Consultation and Supervision

Colleagues and supervisors are a good source of assistance in assessing the ethical risk of situations and may help to avoid ethical problems (Boisen & Bosch, 2005; Daley & Doughty, 2006; Dolgoff, Loewenberg, & Harrington, 2005; Galbreath, 2005; Reamer, 2006; Strom- Gottfried, 2005). The real value of supervision and consultation is the ability to develop an independent assessment of the situation for the social worker. Another professional opinion can add the benefit of different experience or skills and give another perspective on how the social worker’s actions may be seen by others.

The difficulty for the rural social worker is that supervision and consultation are often more difficult to obtain than in an urban setting (Burkemper, 2005; Daley & Doughty, 2006; Ginsberg, 1998). The rural social worker tends to be more isolated from professional colleagues and supervisors and must often function more independently (Burkemper, 2005; Daley & Doughty, 2006; Galbreath, 2005; Ginsberg, 1998; Ginsberg, 2005). Thus, the social worker in rural practice must be more diligent and expend more time in getting essential supervision and consultation. This may be one of the biggest challenges for rural social workers but is essential in order to strengthen their ethical practice in small communities (Burkeper, 2005; Daley & Doughty, 2006; Strom-Gottfried, 2005).

Finding solutions for the difficulties in getting on site supervision require the rural social worker to use some creativity. The wider availability and increasing sophistication of interactive video and Internet as a mean of communication are effective ways to remove the distance barriers inherent in rural settings. The chief concern with these media lies in building in adequate safeguards to protect

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client confidentiality. In addition, judicious use of the telephone may reduce the reliance on face-to-face supervision which is more difficult to get in rural communities. One area of particular concern with phone supervision may be the use of cellular telephones as they broadcast over open airways and these communications could not generally be considered confidential.

12. Use Informed Consent

The multiple and overlapping relationships in small communities clearly present an ethical risk because of the potential for confusion about which role social workers are acting in. For example, is the social worker acting in a professional capacity, a neighbor, fellow church member, or in some other capacity? Confusion of this type can lead to ethical disputes especially when professional boundaries are blurred.

To address these types of risks, the use of informed consent and collaborative work to empower clients are appropriate practice approaches (Burkemper, 2005; Galambos, Watt, Anderson, & Danis, 2005; Gumpert & Black, 2005; NASW, 2008; Strom- Gottfried, 2005). What is suggested is that the role and limitations of the social worker be fully discussed with the client and that clients be empowered to make choices about services. This discussion should include some coverage of how confidential information, meetings in public places, and community conjecture about confidential client related matters are to be handled. Given the close knit fabric of the rural community confidentiality issues, choices for location of services, and service providers may be more likely to arise. Empowering clients by giving them informed choices can help to avoid service locations where the client’s car could be

recognized, thus identifying them as a client. It may also help to avoid issues arising from the use of service providers for which the client has either some type of community connection or about which the client has heard negative information.

Social workers may also wish to consider how information received from colleagues should be addressed in order to avoid misunderstandings that may result in ethical complaints. Ethical principles that apply to colleague to colleague communications are somewhat different than worker to client communications, and not all information exchanged may be confidential. For example, a social worker may share information with a colleague or supervisor about a divorce, mental health issue, or chemical dependency that is affecting his or her work performance. The social worker who receives the information may be obligated to disclose some of that information to the agency, to a licensing entity, or to NASW. Some discussion about the limits of confidentiality that apply in discussions with colleagues may prove useful in preventing misunderstandings.

13. Documentation

Since the burden of demonstrating that appropriate professional boundaries were maintained is placed on the social worker (Boisen & Bosh, 2005; Galbreath, 2005), it is imperative that well documented records of one’s work be kept (Reamer, 2006). Good documentation is sound professional practice (Reamer, 2006). Accurate and detailed records made contemporaneously can document the careful decision making process that the social worker used to act.

Records provide a good source of information to demonstrate that the social

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worker gave careful consideration to doing what is best for the client. Records may also document that supervision or consultation was used as part of the process. Ultimately, documentation may be important because it can help protect the social worker from charges of malfeasance, misfeasance, or nonfeasance (Reamer, 2006).

14. Summary and Conclusion Despite the heightened ethical risks faced by rural social workers, management of these risks is crucial to minimize problems. This manuscript identifies several aspects of practice in small communities to which the social workers may need to pay particular attention. The areas which tend to pose the greatest ethical risk for rural practice include dual relationships, poor practice and competence, confidentiality, anonymity and self-disclosure, and ethical issues with colleagues. To be effective, the rural social worker should be culturally sensitive to the community by using a culturally sensitive perspective as an overlay when applying a traditional ethical decision making framework. The manuscript also identifies some specific strategies for managing these ethical challenges once identified. Strategies such as identifying ethical conflicts, seeking consultation and supervision, working collaboratively and using informed consent, and documentation are common and effective ways of managing ethical challenges.

Ethical issues in rural practice arise, at least in part because of the context as rural communities are often described as close knit or like living in a fishbowl. So it falls to the social worker to act responsibility and set both clear and appropriate boundaries in their own practice (NASW, 2008). For example, the

NASW Code of Ethics does not prohibit dual relationships, but it does place the burden on the social worker to develop the relationship in a way that neither exploits nor harms the client. This implies that when the social worker has to engage clients in a professional relationship where a dual relationship may exist, proper care must be taken to build in appropriate safeguards. One way to do this is by setting clear and appropriate boundaries. Especially in the rural community, setting appropriate boundaries proceeds from a strong understanding of the rural community and rural social work (Boisen & Bosch, 2005; Burkemper, 2005; Daley & Avant, 2004; Ginsberg, 2005; Gumpert & Black, 2005; Martinez-Brawley, 2000) in order to both deliver the best possible service and to navigate the cultural context of the rural community.

The concerns that rural social workers had about dual relationship sections of the NASW Code of Ethics in the 1990s have resulted in a healthy discussion of the ethical challenges of rural social work. This discussion has, in recent years, pushed beyond the bounds of dual relationships to include broader aspects of practice and strategies to manage unavoidable conflicts. Rural social workers already appear to have found ways to manage these conflicts with some degree of effectiveness (Daley & Doughty, 2006). In this sense, practice appears to be ahead of the literature. We still have much to learn about adapting ethical practice to rural social work. Hopefully the dialogue will continue to grow and expand our knowledge about this critical aspect of practice.

References

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