When private nurses enter their clients' homes, some find themselves treated like domestic helpers instead. Others face physical and verbal abuse, or are caught in the middle of their clients' domestic squabbles.
According to some agencies, a nurse got slapped and another was barred from using the toilet at certain hours.
These issues surface even as the Health Ministry works to increase home care places so that Singapore's ageing population can be cared for in familiar surroundings.
In 2011, there were just 3,800 home care places available. As of April this year, the figure has doubled, with the ministry planning to provide 10,000 places by 2020.
Singapore has more than 40,000 nurses as of last year, of which about 10,000 work in the private sector, including private clinics and hospitals.
It is unclear how many private nurses are involved in home care. This group of nurses was cast in the spotlight when a businessman was sentenced to jail and caning earlier this month for molesting a private nurse he had employed to take care of his cancer-stricken wife.
Although sexual assaults are few and far between, the expectation that nurses should perform duties outside their job scope often leads to problems, according to four industry operators interviewed by The Sunday Times. These agencies manage around 1,000 nurses altogether.
Worldwide, the challenge is that caregivers are in the home, and the home is not a professional environment... Being in the home can mean that they don't get the same amount of respect as they would in the hospital, for example.
MS YORELLE KALIKA, chief executive of Active Global Specialised Caregivers.
We can't do anything to stop criminal intent, but we are committed to support our valued nurses and mitigate the risk of an incident. We assure our nurses of their rights to reject a case.
MR JULIAN KOO, co-founder of home care agency Jaga-Me.
It is not uncommon to hear of home care nurses asked to clean, cook or even look after their employers' children, said Mr Julian Koo, co-founder of home care agency Jaga-Me.
A nurse employed by Active Global Specialised Caregivers was told not to use the toilet between 7pm and 8am the next day. It prompted the agency's chief executive Yorelle Kalika to step in.
And in yet another incident, a nurse from ezCare was instructed to prevent one relative from visiting her elderly client - only for that relative to argue for the opposite arrangement. "The nurse was stuck in between," said Mr John Chen, who is ezCare's chief operating officer. "No matter what we do in this kind of situation, the family will not be happy."
He added that stressful situations can also make clients' family members act inappropriately, recounting how one adult slapped a nurse when the person she was caring for had a fall.
The nurse was immediately taken out of that threatening environment, Mr Chen said.
Other instances of harassment or abuse can come from clients themselves. These can be trickier to deal with as such patients may not be of sound mind.
Those with dementia, for instance, often undergo behavioural changes as the disease progresses, which make them more irritable or easily agitated.
One caregiver was constantly pummelled and railed at by a patient when they were in the shower, recounted Ms Kalika. "It's an involuntary automatic behaviour. We gave the patient a toothbrush and it stopped," she said.
When such distraction techniques do not work to calm an aggressive client, drugs may be prescribed by a doctor to help improve their mood, added Ms Kalika, who manages more than 680 caregivers. All of them are trained as nurses or nursing aides in their home countries, which include the Philippines, Sri Lanka and Myanmar.
While providing care at home is a boon for families, the home setting may well be a factor contributing to these negative incidents.
"Worldwide, the challenge is that caregivers are in the home, and the home is not a professional environment," noted Ms Kalika. "Being in the home can mean that they don't get the same amount of respect as they would in the hospital, for example."
Some steps that agencies take to help their staff minimise unpleasant situations include meeting potential clients beforehand.
Comfort Keepers business development executive Sally Benjamin said that its in-home caregivers typically meet patients and their family members for an assessment before taking up the jobs. These home visits, which can last from 30 minutes to an hour, would allow them to assess if both parties are compatible.
This has helped the agency avoid placing caregivers in potentially dangerous situations, she said. "If a dementia patient is too violent with the caregiver around, then it may not be beneficial for us to come in and we wouldn't take it up."
The meetings also let them lay down ground rules and address any expectations.
Ms Benjamin acknowledged that over time, employers could cross certain boundaries as they become familiar with the caregivers. But her staff are trained to be firm in their response.
Added Mr Chen: "Before we start the cases, we already tell clients the scope of our nurses' services. Anything else that nurses do for them comes from goodwill."
He feels that establishing a common set of guidelines for employers could help nip these problems in the bud.
Mr Koo added that all of Jaga-Me's nurses are trained to watch out for red flags that signal potentially problematic situations, and to defuse them if possible. They are also taught how to seek help if things get out of hand.
"We can't do anything to stop criminal intent, but we are committed to support our valued nurses and mitigate the risk of an incident," he said. "We assure our nurses of their rights to reject a case."
•Additional reporting by Ng Huiwen