Author: Andre Coleman

Knowledge based practice

Introduction

This paper will look at how research informs practice. I will be looking at young people and substance misuse and older people and how research might inform or affect my practice.

Good professional practice is knowledge based practice which often means that it is practice based on what others have done, or research that others have undertaken. Research is an important part of most aspects of the human services. In health, in education, and in social work research is important informs our view of the world and can provide a framework for dealing with a particular subject or case. Research has a prominent place in the social services and it is important to the social worker. When people undertake research into areas of social and health care, then these findings and recommendations are generally used to inform practice.

Not only is research important in informing social work practice, it is also important when it comes to Government policy. Like most social workers I have found some research an invaluable asset when dealing with disaffected and vulnerable groups such as young children and socially excluded young people.

Some research may have been undertaken some time in the past but its findings still prove to be useful today. Willis’ (1977 in Giddens 2001) used group interviews (what are sometimes called focus group interviews) in his study of working class boyS and the ways in which the education system attempts to prepares them for the labour market. Both individual and group interviews were used in collecting this data, and while the work has been criticised it provided, and continues to provide useful information about how working class boys communicate and interact. This type of research is a source of invaluable knowledge to someone working with young people. It provides some insights into why youngsters react against authority and why they might act the way they do. Research can be a two edged sword, on the one hand it informs, and on the other it can produce lasting impressions that can lead to oppressive policy making. While Government papers on young people set a framework for social workers, this kind of early research is useful when dealing with them in a practice context. Yet another valuable, yet some might say, problematic, source of information is Bowlby’s (1946) work on why young people commit crime or get involved in substance abuse.

While Bowlby’s work, (which points to maternal deprivation as a cause of problematic behaviour in young people )has been deeply criticised within academic circles his ideas still have a significant impact on current Government discourses on youth. Certainly many social workers find themselves dealing with youngsters who have substance abuse problems and may feel themselves in an ethical dilemma when confronted with some of the policies in this area. One of the worst influences that work such as this has had is the growing tendency to treat anyone who does not conform to society’s norms as sick and deviant. Government initiatives on drugs, more often than not, appear to be targeted at poor and working class communities. Further there is a tendency for these initiatives to link poverty and drugs in the minds of other people. If an adolescent comes from the poorer part of town and is perhaps unemployed then this can lead to people in authority thinking that he/she is more likely to be seen as a drugs user even if they are not. Eley (2002) maintains that this leads to the association of drugs and crime with those who are already underprivileged in society. For social workers this is can be an extremely problematic situation. Do I as a social worker automatically assume something about a young person who is in trouble, and label them as sick and deviant, or do I adhere to what I believe to be the case, that everyone is of equal worth and therefore deserves an equal chance. If I am to abide, in my professional capacity by the 1998 Human Rights Act, then ethically, I could be duty bound to ignore Government guidelines in this area.

Moore (1996) says that Government overstates the case on drug misuse when it refers to drug users as addicts because, he argues, most of the drug use that takes place in Britain is recreational This implies that those who use them are in control of the situation with regard to when they take drugs e.g. weekends, and how much they spend. Theorists are divided on why adolescents take drugs therefore it might be argued that the reason adolescents use drugs are quite complex and differ from person to person. This means that a social worker should act in accordance with the Human Rights Act when dealing with the problems of young people because that also implies treating each case on its individual merits

Becker (1963) has argued that young people are often viewed as delinquent because of the way society viewed certain acts, such as drug taking. Calling or labelling a young person as deviant is problematic because it can become a self-fulfilling prophecy. Those in authority often take the view that young people, and particularly underprivileged young people are deviant and if the label is applied often enough, and by those with the power to apply it, then that is how the adolescent may come to view themselves. Taylor, Walton and Young (1973) however, say that no theory is sufficient unless there is also an analysis of the power relationships that exist in society. Hall (1978) maintains that the way in which adolescents are represented in the media has a huge effect on the way in which they are viewed by others. This can then have a further effect on their actions.

In my own professional practice I have to be aware of such theories and how they inform public perception and Government policy. I also have to be aware of them in my practice and this might involve questioning the assumptions and methods behind certain research findings i.e. I am questioning their theories. Theories aid us in making sense of the world, one explanation of theory is an observation of observed regularities for example that women do more housework than men. Many things are not self-evident but need an explanation, thus Abbott and Wallace (1997) maintain that all of us are theorists because of the need to analyse and interpret our ordinary everyday experiences in order to make sense of them

In sociological theory, some theories are extremely abstract, for example critical theory. Merton (1967 in Giddens, 2001) has called these theories ‘grand theories’ because they operate at a general and abstract level, theories such as those of Willis and Bowlby are middle range theory, because they are looking at an aspect of social life. Usually Merton (1967in Giddens 2001) maintains it is the middle range theories that are more likely to guide research. Labelling theory and Becker’s work, for example is a middle range approach to research that was developed out of the sociology of deviance. The problem is that while I as a social worker dealing with a young person with substance abuse issues might prefer to treat that person as an individual, and ethically I am bound to do so, Government discourses take a quite different view. Drug abuse and crime as mentioned earlier are closely associated in public discourses with poverty and this is evident in recent policy making. When evaluating research and research findings social workers need to find some sort of framework within which to evaluate the work this might be the 12 step approach advocated by Locke or it might be something as simple as using a content analysis approach to evaluate what the researcher has done and decide how effective that research may be.

The Government’s report, No More Excuses (The Causes of Youth Crime) states that deprivation and poverty are usually a contributing factor in youth crime.^[1] Government research suggests that while young people who offend may not do it very often, there are a few persistent offenders who are responsible for the greater part of youth crime new Youth Justice reforms will concentrate on preventing crime and on early intervention where children and young people are at risk of becoming involved in crime.^[2] Leitner et al (1993) maintain that the British public is concerned about drug use, drug dealing, and the crime that is associated with this. Pudney (2003) maintains that if young people take soft drugs such as cannabis then they are more likely to progress to hard drugs and to criminal activity. He also argues that such behaviour is strongly associated with unobservable personal characteristics and New Labour have consistently targeted drugs initiatives at underprivileged communities.

Working with young people means that I have to take into account Government reports as well as other research findings. At the same time I, like many other social workers, have as Moore (2002) points out, entered social work because of a commitment to social justice, or at the very least a desire to help others and to see improvement and positive change in people’s lives. Some critics maintain that the way in which social services often operates is self-serving rather than serving the needs of the clients, yet social workers do police themselves and their profession. The way in which they do this is to think critically about what they are doing, why they are doing it, and what moral implications this may have. Certainly social work ethics should not lead anyone to believe that the social work profession should serve itself, rather the needs of the client should be most important. One of the ways this is achieved is by establishing clear relationship boundaries early on and this is vital when working with young people who have issues around substance misuse. The BASW has to say about social work ethics and values.

The social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. Utilising theories of human behaviour and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work (BASW,2001). ^[3]

Social work practice, in order to be ethical practice must be centred on the needs of service users Social workers of necessity intervene in people’s lives and have an influence on situations, ethical decision making is therefore a vital component of social work practice (Osmo and Landau, 2001).

Yet another area where social work practice can be a minefield is in working with older people. When working with older people a social worker has a duty to abide by the 1990 NHS and community care act. Working with older people can be difficult on the one hand there is what you want to achieve as a social worker and on the other there are guidelines that may prevent you from doing your best for a client. There are an increasing number of legal and policy requirements that the social worker dealing with an older person must adhere to. It is difficult for the social worker to negotiate the needs and wishes of the client while remaining within the legislative framework. Working together is not always straightforward. The more recent Health and Social Care Bill of 2001 gives Government powers to require health bodies and local authorities whose services are failing to pool their resources. Parrott (2002) undertook research into the care management process and how it affects social workers and service users. He points out that there is often no common guidelines on which services should be provided, or the standard of care to expect. The social worker may find that he/she has to perform most of the assessment and to discover whether an older person’s family would be prepared to help so that he/she could remain in their own home. Whatever the decision the social worker would also need to ensure that the client could, at some level, participate in the decision making process. Thus the process is fraught with problems, for example a social worker might assess a person as needing a certain level of care but this has to be agreed with the social worker’s supervisor and with care management. So the person may not receive the care that the social worker deems appropriate. Thus the social worker has a dilemma. While knowledge does inform practice it is not the only thing that the social worker has to deal with, management decisions also affect the process as Parrott’s research shows. One thing that has become apparent to me is while research can inform practice, it should not be allowed to determine it, if and when it does this can result in oppressive practice and a complete disregard of the rights of the service user and this is against ethical practice as outlined by the BASW.

Conclusion

This paper has looked at knowledge based practice and how research informs what a social worker does. When dealing with research one is not looking at it in isolation but also having to deal with policies that emerge as a result of that research. Many of the funding restrictions that social workers have to deal with are a result of the 1988 Griffiths report which found that getting organizations to work together, and using a market based approach to social care would save the Government money.

Bibliography

Abbott and Wallace (1997) An Introduction to Sociology: Feminist Perspectives, London, Routledge

Becker, H.S. 1963. Outsiders. New York, Free Press.

Bennet, T. Holloway, K. and Williams T. 2001.Drug use and offending: Summary results of the first year of the New-ADAM research programme. Home Office Research Study 236 Home Office London

Blaxter, L, Hughes, C and Tight, M (1996) How to research. OU press

Bowlby, J. 1946. Forty-four Juvenile Thieves. London, Tindall and Cox.

British Association of Social Workers (2002) The Code of Ethics for Social Work.http://www.basw.co.uk/.

Bryman, A 2004 Social Research Methods 2^nd ed. Oxford, Oxford University Press

Eley, S. 2002. “Community-backed drug initiatives in the UK: a review and commentary on evaluations.” Health & Social Care in the Community10(2),99-105.

Giddens, 2001 4^th ed. Sociology Cambridge, Polity

Hall,S. Critcher, C. Jefferson,T. Clarke, J. and Roberts, B. 1979 Policing the Crisis. Mugging,

Leitner M., Shapland J. & Wiles P. 1993. Drug Usage and Drugs Prevention: The Views and Habits of the General Public. HMSO, London.

Moore, S. 2002 3^rd Edition Social Welfare Alive Cheltenham, Nelson Thornes

Moore, S.1996 Investigating Crime and Deviance London, Collins Educational

Parrott, L 2002 Social Work and Social Care London, Routledge.

Taylor Walton and Young. 1973. The New Criminology. London, Routledge

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Topic: Not everyone is suitable to do crisis intervention work as it is very demanding for the helper. Do you agree? Support your answers with relevant research.

Theoretically speaking almost anyone can be a crisis worker by reading books and practicing the skills but to make interventions effective it is not enough. James and Gilliland (2008, p. 21) stated that almost anyone can be taught the techniques of crisis intervention in a book and apply these techniques to some degree of skills, however it takes more than reading up techniques through a book and mastering the skills to make intervention effective.

Crisis has different meanings to different people; a person may feel deeply affected by an event, while another suffers little or nothing at all, for example, in a conservative society, when a teenage girl discovers that she is pregnant, it is a crisis, but a married woman who is not able to have children is another kind of crisis. As each individual reacts differently, crisis workers need to understand what crisis means to the individual from their point of view as it is crucial in crisis intervention (Coulshed & Orme, 2012).

James and Gilliland (2008, p. 3) define crises as events or problems which are intolerable difficulty that goes beyond the limit of an individual’s resources and coping mechanisms. An individual is in crisis when their important life goals are obstructed by difficulties that they could not resolve within their available resources. It refers not only to an individual traumatic situation or event, but also the individual reaction to an event.

According to Aguilera (1998) in a 1959 address John F. Kennedy stated, “When the word crisis is written in Chinese, it is make up of two characters, one symbolizes danger and the other opportunity” (p. 1). Crisis is danger because it threatens to overwhelm an individual, and it may result in suicide or mental illnesses in extreme cases. On the other hand, it is also an opportunity as it provides the client opportunities to learn new coping skills and function at a higher level equilibrium state than before the crisis.

Crisis intervention is an immediate person to person assistance. It helps people who face crisis to restore self-determination and self-confidence (France, 1996). Crisis workers assist people in crisis by searching alternatives for solutions by encouraging them to consider and clarify their thoughts, feelings and options. Aguilera (1998, p. 26) stated that the therapeutic goal of crisis intervention is to enable the individual in crisis to regain emotion equilibrium or gain higher level state of equilibrium than before the crisis.

In the event of a crisis most people tend to avoid intervention in order to stay out of trouble, however there are people who would try to intervene out of good intentions but they might not be the right person to help and may even worsen the situation. People with type A personality are not suitable for crisis work as they are very competitive, impatient and easily aroused to anger. They experience a constant urgency struggling against the clock and become impatient with delays and unproductive time (McLeod, 2011). People with such personality are not suitable for crisis intervention work as they do not have the patience to observe and understand the situation. Although speed is essential, crisis workers must have the patience to communicate with the person in crisis and not aggravate it by getting angry themselves when the problem is not solved. Hence, not everyone can be an effective crisis intervention worker.

The job of a crisis worker is to define crisis as perceive by the individual and attend to the immediate problem, which is to understand and use the fastest method to solve the problem at hand. Once the situation is in control and the person in crisis has calmed down, the case will be handed to other professionals for follow-up as crisis workers do not need to solve the root problem. In addition past experiences and the crisis worker’s personality and characteristics like life experience, poise, creativity and flexibility, energy, resilience and assertiveness affects the worker’s ability to handle different situations.

Life experiences are rich resources for a crisis worker as it comes with emotional maturity. Workers who had overcome crisis in life gain perspectives by learning from those experiences and use their experiences to help people who are in crisis like them before. Although life experience is a rich resource, it can weaken the crisis workers if it influences them in a negative way (James & Gilliland, 2008).

As the situations are often shocking, unpredictable and unexpected, crisis workers need to remain calm and steady, to provide an atmosphere that is stable and rational for people in crisis. James and Gilliland (2008, p. 22) stated that “an effective crisis worker is as steady and well anchored as a Rock of Gibraltar.” meaning that an effective crisis worker is stable and solid as stone and remains calm and collected who is not afraid, tense nor anxious during a crisis. Also, being poise is one of the significant qualities a crisis worker should have.

Different crisis requires different methods to resolve. Hence, crisis workers need to be creative and flexible when dealing with crises that are complicated and appears to be unsolvable. Although crisis workers do not have the answers to every question, they are expected to be competent in problem solving, guiding and supporting the person in crisis towards crisis solutions (Aguilera, 1998).

Occasionally, crisis workers may need to employ untraditional approaches to solve difficult situations. How creative an individual is in finding solutions during difficult situations depends on how well they have natured creativity through the course of their lives (James & Gilliland, 2008).

In addition, crisis workers need energy as crisis work is very demanding, tedious and intense who often need to assess, organize and direct situation. James & Gilliland (2008, p. 22) highlighted that crisis workers take care of themselves in both physical and psychologically, and uses wisely of their available energy.

Also, crisis workers need to have some degree of self-knowledge about their own abilities and understanding, particularly to the extent of being resilience during difficult situations, such as working with offensive or aggressive people (Trevithick, 2005). During crisis, people are often hostile and do not talk much, hence crisis workers would need to be assertive and set limits to behavior so as to keep the person stabilize and also to maintain own integrity (James & Gilliland, 2008).

As Trevithick (2005, p. 72) stated for a crisis worker to make an intervention effective, it involves being able to recommend the right courses of action, the right choice of generalist skills and the specialist interventions connected with a particular practice approach. Besides using knowledge to describe the mandate for involvement, crisis workers need to be able to set the intervention in ways that address the needs and expectations of the individual in crisis.

During threatening situations, one needs to learn how to make assessment and deal with the people involved. Hence, practicing a model for crisis intervention can help crisis workers to be aware of the components of an effective response to crisis. James and Gilliland (2008, p.37) stated that, it is worth having a model of intervention for crisis workers that is direct and effective.

James and Gilliland (2008) developed a six-step model for crisis intervention. This model focuses on listening and acting in a systematic manner helping people in crisis to regain back to an equilibrium state. The first three steps are focused more on listening while the last three steps are focused on actions.

First, defining problem is to understand the issues from view point of the individual in crisis. This requires core listening skills, congruence, acceptance and empathy. Second, ensuring safety is necessary by keeping the individual and the crisis worker safe by reducing any possibility of physical and psychological danger. Ensuring safety is a continuous part in the process of crisis intervention. Third is providing support by communicating care and emotional as well as informational support for the individual (James & Gilliland, 2008).

Fourth, examining alternatives, which is often neglected by the individual and worker, is to consider different options available to decrease the intensity of crisis and defuse the situation by selecting the best alternative that best fits the situation (James & Gilliland, 2008).

Fifth, making plans where the individual is supported to make a very detailed plan from the alternatives that are positive and achievable. Collaboration is important in order to let the individual have a sense of ownership of the plan to regain order, as France (1996, p. 48) had stated order can come to what has been a chaotic situation as the individual work on a plan; a sense of self-control and enhanced self-esteem can be attained when an individual attribute tangible progress to their own efforts and realistic hope can grow as the individual plan courses of action and experience success.

Lastly, obtaining commitment from the individual either verbally or a written commitment that can be comprehended and carried out by the individual. The goal is to let the individual commit to the plan and take definite positive steps designed for them to move towards regaining a pre-crisis state of equilibrium (James & Gilliland, 2008).

In conclusion, almost everyone can learn crisis intervention through reading books and practicing and mastering the skills in intervention, however, an effective crisis worker needs more than a strong base of theoretical knowledge and technical skills. The characteristics and the personality of a crisis worker also affect how an individual handles a crisis and it also requires great amount of energy to meet the demands of the job. Thus, not everyone is suitable to do crisis intervention work.

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An Analysis of a Range of Issues in Quality Frameworks, Processes and Methods of Measurement in Mental Health Work and Social Work Practice

Introduction

In equating the various range of issues with respect to quality frameworks, processes as well as methods of measurement in mental health work and social work practice it is important to understand the meaning of these terms as well as their respective applications in the United Kingdom, which represents the subject focus for the aforementioned. Mental health is defined as (Houghton Mifflin, 2006):

“ A state of emotional and psychological well-being …” whereby individuals are able to utilize their respective “… cognitive and emotional capabilities …” to function as members of society as well as to “… meet the ordinary demands …” which are a process of daily living”

In the context of mental health services it relates to “A branch of medicine that deals with … achievement and maintenance …” (Houghton Mifflin, 2006) of the psychological well-being of individuals. The International Federation of Social Workers (Bouldertherapist.com, 2006) defines social work as a profession that “… promotes social change, problem solving in human relationships …” as well as giving individuals the empowerment and liberation “… to enhance their well-being”. The profession, as maintained by the International Federation of Social Workers utilizes “… theories of human behavior and social systems …” in a context whereby the profession intervenes and interacts with individuals at the areas where they “… interact with their environments” and whereby the principles of both human rights as well as social justice are underpinnings in the field of social work (Bouldertherapist.com, 2006). These two fields have a denominator in common, which is that they exist to serve people and help them to improve, as well as cope with their aliments and to ultimately return to a healthful state.

The process of serving individuals in this capacity represents some of the most challenging professions in that the analysis of effectiveness, quality, processes and the methodologies utilized in measuring the aforementioned with respect to the varied issues arising from the active practice can be subjective in most instances. This examination shall look at the mental health and social work professions from the context of a range of issues representing quality frameworks, processes and methods of measurement to determine the progress made in providing better service and quality to patients and carers.

Total Quality Management

Deming (Aquayo, 1991, pp. 138, 248), Crosby (1980, pp. 212-223) and Juran (1992, pp. 171) are all proponents of ‘Total Quality Management’ which is a strategy dedicated to building into an organization the awareness of thinking in terms of embedding quality in all phases of an organization’s processes. The International Organization for Standardization (2006) defines ‘Total Quality Management’ as being “… a management approach … centered on quality … which is … based upon the participation of all its members … that aims at long-term success …” (Wikipedia, 2006) achieving the foregoing through customer and or client satisfaction that generates “… benefits to all members …” (Wikipedia, 2006). The preceding includes the organization itself as well as society. In equating quality, the usual context in which one thinks of this word is in products, rather than services such a those products which are made with a minimum of problems, of good materials and which work properly and achieve this through consistent operation. However, quality as an end result is an organizational mind set, and as referred to in the International Organization for Standardization (2006) definition as a process “… that aims at long-term success …” achieving the foregoing through customer and or client satisfaction that generates “… benefits to all members …” (Wikipedia, 2006).

Deming (Aquayo, 1991, pp. 6-10) is an American consultant who exposes the importance of implementing a quality oriented organization that permeates every facet of an organization’s structure and culture, regardless of department or function. Deming (Aquayo, 1991, pp. 8) states that organizations must produce “… products and services that help people to live better” and that the preceding “… is the raison d’etre …” (Aquayo, 1991, pp. 8) of the organization. His philosophy is that through the adoption of quality products and services, which is a function of management inculcating its staff in quality and innovation measures, the end product and or service improves as does its relationship with its customers and or clients. Crosby (1980, p. 1-5) indicates that mistakes or poor organizational habits and or policies are costly in terms of corrections and the damage to reputation and morale and that all members of an organization have the responsibility to perform their jobs which enhances the performance of other functions thus becoming a synergistic effect. Crosby (1980, p. 4-8), as does Deming (Aquayo, 1991, pp. 6-10) and Juran (1992, pp. 171) all emphasize the importance of quality in increasing an organization’s ability to provide services that meet and exceed client expectations through the effect that quality orientation has on internal interpersonal relationships and openness to ideas.

The heart of the work level philosophies held by Deming (Aquayo, 1991, pp. 138, 248), Crosby (1980, pp. 212-223) and Juran (1992, pp. 171) is the contribution of ‘quality’ to the equation of improved services and innovation in heightening organizational standards. The term ‘quality’ can thus mean in this context (Wikipedia, 2006):

the excellence and or achievement of an object or service, meaning that it is not inferior or sub-standard,
a meaning of excellence in its own right

‘Quality’ is a term in this context that is synonymous with good, which represents the criteria utilized as the standard being applied. Deming (Aquayo, 1991, pp. 138, 248), Crosby (1980, pp. 212-223) and Juran (1992, pp. 171) equate this word in the following manner:

Deming (Deming, 1988) states that improved quality helps to reduce operating costs through less error and correction measures. He indicates that to attain the preceding a consistency of purpose needs to be inculcated throughout the organization with an overall plan that is maintained. Deming (Deming, 1988) stresses the need for improved consistency on an ongoing basis and to remove the barriers between various departments to increase and improve communication, feedback and intra-company working processes. Deming’s (Deming, 1988) thirteen point program stresses that it is management that leads and sets the example as well as supports ongoing quality through active participation that involves everyone within the organization as well as suggestions and contributions from working partners and clients.
Juran (1992, pp. 154-198) states that quality application in organizations is defined by crafting them to be utilized in context with the organizations purpose to improve performance.
Crosby (1980, pp. 189-216) also trumpets the application of quality throughout the organization as a management down function that must be maintained, taught as well as communicated to bring the staff not only on board, but committed to the adoption of quality and improvements as an organizational way of thinking.

Moullin (2002, pp. 2-7) advises us that quality in health and social care fits within these fields as it is important to:

patients as well as service users,
staff, and
the application of quality can aid in the reduction of costs as well as provide better service in the context of budgetary and cost constraints.

It is interesting to note that Moullin’s (2002, pp. 2-7) points are the same as those emphasized by Deming (Aquayo, 1991, pp. 138, 248), Crosby (1980, pp. 212-223) and Juran (1992, pp. 171) in the general context of total quality management, and that the application in the health and social care fields is the same as for manufacturing, banking, or any other industrial sector. Moullin (2002, pp. 2-7) points out that quality in the health and social care fields is important in that not only do patients as well as service users benefit in that their differing requirements are met in a better, more comprehensive and complete fashion, the benefit of quality also affects both these groups each time they come into contact with the organization(s) and thus their individual confidence levels rise with the expectation that they will receive good service and be well treated. Moullin (2002, pp. 5) advises that patients in need of health and social services are usually stressed, worried, vulnerable as well as frightened with respect to the outcome of their need(s) and that long waits on the telephone, in lines, for responses, little or insufficient information, poor facilities and insensitivity exacerbate the preceding. He (Moullin, 2002, pp. 6-8) indicates that quality in these fields, health and social care, is important in that:

The staff benefits as the vast majority elected for a career in these fields out of a desire to help others, rather than for monetary gains and that poorly organized staffing functions contribute to frustrations for employees reducing their morale as well as effectiveness.
Moullin (2002, p. 6) adds that quality is important in the reduction of costs as he advises that the correlation between resources and quality represents a strong relationship. And while the amount and number of staffing is important, quality can be improved irrespective through the application of new innovative techniques, technology, work flow planning, scheduling and other means. Moullin (2002, p 6) indicates that reduction in costs sometimes means increasing services and or staffing in one area whereby the work load flow will thus lessen the impacts on another thus either balancing out or reducing costs through flow adjustment.

While it is difficult to place an exact date or year on when quality became an active force in the health and social care sectors, the concern over spiraling health care costs, inefficiencies and deteriorating services began to surface in the late 1970’s and early 1980’s in the United States, as well as a result of the increasing costs burdening the governments in Europe’s socialized medicine schemes (Bennett et al, 1999). The era of unlimited access and treatment as the foundation of quality oriented services in the health and social care fields began to give way to the spiraling costs of advancements in diagnostic techniques and therapeutic modalities, with the rising costs of health and social care exceeding the rise in the costs of living in the United States as well as Europe and the expenditures for socialized medicine threatened the economies of many nations in Europe (Lighter, 1999, p. 265). In addition to the foregoing, the aging of the world’s population as better medical care has increased life spans, and this combined with the fertility transition has increased the proportion of older adults and has contributed to the concern for quality in health and social care (Demeny et al, 2003). Health care spending in most OECD (Organisation for Economic Co-operation and Development) countries, such as (OECD, 2006):

Australia
Austria
Belgium
Canada
Czech republic
Denmark
Finland
France
Germany
Greece
Hungary
Iceland
Ireland
Italy
Japan
Korea
Luxembourg
Mexico
Netherlands
New Zealand
Norway
Poland
Portugal
Slovak Republic
Spain
Sweden
Switzerland
Turkey
United Kingdom
United States,

amounts to in excess of eight percent (8%) of their Gross Domestic Product (GDP), with health related spending in the United States projected at fourteen percent (14%) (World Trade Organization, 1998). The public’s concerns over increased costs for health and social care services prompted the privatization wave on the mid 1980’s in the expectation that the measure would increase efficiency as well as reduce costs, but those expectations from this initiative have been elusive (Bach, 1989). The preceding created a climate whereby governments in Europe under socialized medicine, as well as the private health care structure and governmental social care system in the United States began to look for measures to control and reduce costs while increasing quality.

In 1998 the Department of Health in the United Kingdom issued a ‘White Paper’ titled “Modernising Social Services” (Department of Health, 1998) which represented the United Kingdom governmental response to public opinion as well as mounting social care costs to introduce quality frameworks into the system. The White Paper set forth a framework at the national level that called for (Department of Health, 1998):

the establishment of “… clear objectives for social services…”that created a “… clear expectation of outcomes …” which social services would be “… required to deliver.” (Department of Health, 1998),
the publication of a “… National Priorities Guidance…” (Department of Health, 1998) that set up key targets that social services would achieve in the intermediate term, and
putting into place “… effective systems …” (Department of Health, 1998) via which to monitor as well as to manage performance.

The Department of Health’s White Paper in 1998 clearly set forth that the government of the United Kingdom was putting into place “… new resources to support …” (Department of Health, 1998) the programme, and in return for these added resources, pegged at ?1.3 billion over 1999/2000 – 2001/2002, and the United Kingdom government made it clear that it expected “… to see improvements in quality and efficiency …” (Department of Health, 1998). The Best Value framework represented another name for Total Quality Management in the context of health and social services care in the United Kingdom. Under the “Best Value” framework indicated under this White Paper, the government set forth that (Department of Health, 1998):

Local authorities were mandated to establish “… authority wide objectives for performance measures” (Department of Health, 1998) in consort with the national objectives as well as government set standards and or targets.
Local authorities were also provided with the responsibility to conduct and “… carry out fundamental performance reviews …” (Department of Health, 1998) concerning all their services in a five year framework utilizing these reviews for assessment and the establishment of “… local performance plans…” (Department of Health, 1998).
That the local planning process will be underpinned and supported via data obtained “… from a new statistical performance assessment framework” (Department of Health, 1998).
“… Local Performance Plans …” will be utilized to identify the targets for improvement compared against performance indicators on a local level and “…. The National Best Value Performance Indicators …” (Department of Health, 1998).
Annual reviews of the aforementioned local performance plans will be conducted by the Department of Health utilizing Social care Regional Offices to assess progress and identify problem areas (Department of Health, 1998).
The White Paper put into place an independent inspection system utilizing data from the performance assessment framework (Department of Health, 1998).
And lastly, the ‘Modernisation’ programme set forth a system of Joint Reviews reducing the time table to five years from seven (Department of Health, 1998).

The new programme set forth a performance assessment framework that specified performance areas defined by (Department of Health, 1998):

cost and efficiency,
effectiveness of service delivery and outcomes,
quality of services for users and carers, and
fair access.

Analytical Methods of Quality Measurement and Standards

Balanced scorecards represent a top-down hierarchical set of management tools that link long-term financial goals with performance targets (Kaplan et al, 1996, pp. 75-84). The United Kingdom’s National Health Service utilizes what is termed a ‘Star Rating’ system which is an example of the balanced scorecard (British Library, 2002). Kaplan et al (2001) advise that this methodology, specifically designed for the public as well as voluntary sectors has a link between performance measures and strategy, and thus the method should represent one of benefit in these regards. The caveat is that there are varied difficulties arising from its use by organizations as the financial perspective measurement is not the defining factors of organizational purpose in the public sector (Dickson et al, 2001, pp. 1057-1066). Kaplan et al (2001, pp. 135) agree with the foregoing and add that in utilizing the balanced scorecard governmental agencies should consider the utilization of an overarching objective at the head of their respective scorecards which is reflective of the long-term objectives (Kaplan et al, 2001, pp. 135). The difference in the utilization of the balanced scorecard in a not for profit and governmental agency mode as opposed to business is the way stakeholders are considered. In a business atmosphere stakeholders are involved as it represents the best means to conduct business, however in a not for profit and governmental agency sense, these organizations usually exist for the benefit of the users of the service as well as other stakeholders thus changing the emphasis whereby stakeholder contribution is more fundamental (Moullin, 2002, p. 167). Moullin (2002) adds that user involvement takes place at two levels, one represents helping to develop the service to meet their needs and the second entails the involvement of users and carers in the decisions concerning their health as well as the care given and received.

Benchmarking, as a term, has numerous definitions, however at its core it represents a process of “…sharing information, learning and adopting best practices …” (PSBS, 2006). The European Benchmarking Code of Conduct states that it is a process of making comparisons against other organizations and thus learning from the lessons these comparisons reveal (The European Benchmarking Code of Conduct, 1998). In the context of social care, benchmarking entails the understanding or and utilization of knowledge gained across a range of services and compilations to utilize in formulating standards of measurement as a guide to rating and understanding the performance of services in individual local authorities. The weakness of benchmarking is that it can not stand as a total measurement without revision and modification as newer and more effective techniques and methods prove themselves. Thus as a standard in a state of flux, benchmarking represents a system that is based upon existing methodologies, that are changing, being modified and or amended. Thus benchmarking represents a useful, yet temporary methodology whereby the practitioners must be mindful that existing standards are subject to change, which in conjunction with other measurement methodologies has contributed to improving quality and performance in the health and social care sectors.

Quality Approach

The utilization of balanced scorecards, and benchmarking fall under the concept of Total Quality Management which is termed Best Value under the Department of Health’s Modernization Programme and is illustrated by an example provided by Gillian Crosby (2004, pp. 7-8), the Director of the Centre for Policy on Ageing. She indicates that the problem in the social services arena, is wrongly based in concentrating on the solving of their problems as well as users of services rather than as their being active contributors to society. Crosby (2004, pp. 7-8) indicates that the NHS views social care as well as society’s older individuals as a “problem” which in what Crosby (2004, pp. 7-8) terms a “… very narrow approach …” thus creating a focus on delivering intensive services which thus “… excludes … older people and their careers”. She further states that in the aspect of quality as it relates to social services the systems of initiatives, pilots, and projects that have been created and put into place to audit, evaluate, monitor and investigate service development and provisions have been in place for years. Crosby (2004, pp. 7-8) maintains that the problem is the “… sustaining and maintaining …” these areas and “… building them into effective …” provisions through utilizing these collective findings and synthesizing that information. Crosby (2004, pp. 7-8) indicates that this void causes good ideas to stagnate rather than permitting them to be explored and utilized where warranted and she cites that quality thus suffers as a result of duplication and what she terms as “… pilot fatigue …”, indicating that the system needs to implement as well as create and find more innovative ways in which to service elder citizens in a manner whereby these initiatives are “… developed and maintained.” Crosby (2004, pp. 7-8) that there are numerous examples of individual cases whereby instances of good practice have been demonstrated through partnerships that have improved service provisions for elder citizens, citing the “London Older People’s Service Development Programme” as an example. The preceding utilized a collaborative model that promoted optimized care and independence and grew into a tool implemented by the National Service Framework for Older People in London with the hallmark being its “… single assessment process” (Crosby, 2004, p. 8).

The foregoing example is an instance whereby the practice of Best Value and allied tools need improvement to respond to the specialized needs of a segment of social care services, but this example does not indicate that system wide the measurement has not produced results. The system has shown “mixed progress” as reported by the BBC (2005) as the quality of care has improved since the adoption of the Modernization Programme, but as the BBC (2005) reports, “… there are still worrying gaps …” with regard to service as reported by inspectors. The BBC (2005) report indicated that three quarters of the council departments received ratings “… in the top two categories …” as opposed to slightly “… over two thirds in 2004”. Thus progress has been made as a result, yet there is still sufficient room for further improvement.

The NHS Mental Health sectors foundation for improvement in its quality of services was set forth under the National Service Framework in 1999 which established a blueprint for care throughout the United Kingdom …” (Department of Health, 1998). The initiatives established for a modern NHS resound with the word ‘quality’ as its foundation (Appleby, 2000, pp. 177-291). The process filters down into every job description utilizing the word “quality agenda” (Appleby, 2000, pp. 177-291) which is composed of six elements:

treating patients as well as service users with the dignity they deserve,
the creation of the proper environments via which patients can recover and utilizing their views to accomplish how services should be developed,
recognition of the skills of families in the roles of carers,
linking service activities to needs so acutely ill individuals receive urgent care access through a comprehensive range of services,
making the best as well as most effective treatments available, and
emphasize patient safety

The success of the system is contained in the regional rating system which measures the number of ‘Local Implementation Plans’ in red, amber and green (Appleby, 2000, pp. 177-291). The National Service Frameworks set measurable goals as follows (Department of Health, 2006):

the setting of national standards and the identification of key interventions with respect to defined service and or care groups,
placement of strategies that support implementation,
establishment of means via which to ensure progress in defined time frames,
introduction of the new NHS and A First Class service that re-emphasized the position of NSF’s as the key drivers in the deliverance of the modernized agenda.

The success of the NSF is assessed by what are termed interface indicators which are a part of the performance assessment frameworks which has seen demonstrated improvement throughout the system as a result of the Department of Health Modernization Programme and as contained in the Mental health NSF Performance Report of July 2005 rated all ongoing programs as meeting the prescribed targets of achievement (Mental health NSF, 2005). In 2005 26 councils received the three star top rating, which represented an increase of six councils over the prior year (BBC, 2005). The total results indicated (BBC, 2005):

83 councils received two starts as opposed to 78 in the year 2004,
31 received one star, which represented a decrease from 36 the year before,
3 received zero stars, which decreased from eight in 2004.

The foregoing indicates that the Modernization Programme has demonstrated progress and as a result of the varied programmes and measurement systems there is in place a means to equate progress.

Clinical Governance is a term and process which grew from the commercial arena under standards for financial management for companies in the private sector (Palmer, 2002, pp. 470-476). In the framework of the NHS it represents a methodology and framework whereby organizations are accountable for the continuous improvement in the quality of their services as well as high standards of care through the creation of a climate and environment whereby excellence with regard to clinical care grows (Department of Health, 1998, p. 33). Since the implementation of the Department of Health’s modernization programme NHS community and acute trusts have been charged with the creation of established structures as well as processes for clinical governance which is monitored by the CHI. It represents a comprehensive approach comprised of four areas (Palmer, 2002, pp. 470-476):

definitive and clear lines of responsibility for overall clinical care quality,
programme of quality improvement regarding activities that includes a clinical audit,
development and utilization of clear policies that manage risks,
procedural methodologies for all groups to identify as well as correct poor performance areas

The heart of the system is the clinical audit which places accountability on the managers and utilizes performance management as the process of delivering the objectives throughout organizations to filter down to each individual and job description thus providing management with clear roles and set priorities. The programme has been rated as successful in terms of it providing a clear set of measurement data to gauge and compare progress through point in time comparisons under its clinical audit segment which represents a new system that did not exist (Palmer, 2002, pp. 470-476). As such it has aided in the achievement of measurable improvements in the field of patient care, making such an established routine.

The Commission for Social Care Inspection utilizes a framework of fifty performance indicators that when assessed as a whole provide an overview of the manner in which local councils are serving the needs of their residents concerning social care service delivery (East Sussex County Council, 2006). Inspections are carried out a minimum of once in a three year period and can be conducted at any time and is comprised of three types of inspections (Commission for Social Care Inspection, 2006):

Key Inspections:

These are comprehensive and through inspections that are unannounced and are conducted at least once for all adult social care services during a year period. It represents on sire as well as documentation reviews and inspections of all areas of service categories without any prior notice.

Random Inspections

This type represents targeted specific issue inspections conducted in addition to key inspections in the follow up of complaints and or progress from an earlier inspection calling for specific areas of concern.

Thematic Inspections

These inspections represent follow up to regional and or national issues concerning medication, nutrition or similar areas and are also in addition to key and random inspections which can be conducted at any time.

The preceding inspections provide the formulation for ratings and represent a gauge on progress, standards and adherence to established policies. The performance indicators represent fifty differ areas ranging from (National Statistics, 2005):

Children’s Pls
placement stability
employment, education and care leavers education
unit cost of residential care
unit cost of foster care
children reviews
core assessments
long term stability
children in need
Adult Pls
emergency admissions
drug treatment program participation
unit costs of residential and nursing care
adults at home
services for carers
client reviews
carer assessments
waiting times

The methodology has been successful in terms of providing a measuring device via which the CSCI can assess progress and improvements as well as backward movements in services. The audit commission’s role promotes the utilization of performance data to fuel improvements in services provided to the public (Audit Commission, 2006). The Audit Commission works with varied governmental departments, agencies and local authorities to define a broad array of performance indicators applicable to their circumstances. As a department the Audit Commission’s success is represented by the performance indicators it assists in the development of for the aforementioned and is a success as these varied programs have improved the ability of these agencies, departments and local councils in assessment of the services under their charge.

Conclusion

The NHS Modernization framework has been devised to oversee and create improvement in the world’s largest government public sector health and social care programme which stands in excess of ?9 billion and is responsible for delivering a huge variety of services to every corner of the United Kingdom (Department of Health, 2006). Serving individuals in these sectors represents a demanding subjective function whereby the standards of quality and service delivery are defined by consistently improving services and new methodologies which change the standards as innovation introduces newer and improved techniques. Total Quality Management represents a technique that under the NHS Best value programme and Modernization plan of 1999 offers a means via which the system can monitor itself as well as agencies and local authorities with the foregoing fluctuating basis and improve its quality of service delivery in keeping with changes and improvements in care.

The preceding is important as a result of the lessons learned in spiraling health and social care costs that surfaced in the late 19

Work-life conflict occurs when time and energy demands imposed by our many roles become incompatible with one another; participation in one role is made increasingly difficult by participation in another. Work-life balance (WLB), from an employee perspective, is the maintenance of a balance between responsibilities at work and at home.

When the employees have conflicts between their work life and personal life it creates distractions in their work, preventing employees from performing in their best level, which creates obstacles in the achievement of organizational and individual goals. Therefore failure in managing work-life conflict among the employees could lead to problems within the organization.

Hemas Hospital is a newly started hospital in Sri Lanka in the year 2008. It is a multi specialty hospital which caters for the whole family by providing highly specialized medical services according to the highest international standards. Around 100 consultants practice in this hospital.

As a newly started hospital working for 24 hours they are confronted with problems of employees struggling to strike a balance between their work and life. Employee’s commitment to their service is vital to provide to provide a according to the standards.

At Hemas Hospital Nurses play a major role. “Professional nursing is a highly skilled practice directed towards improving the health status of individuals, groups and communities. Nursing activities encompass promoting health, preventing disease, aiding and supporting people in daily living as well as during recovery and rehabilitation, and helping people to die comfortably and with dignity” (“Nursing”, n.d.).

The purpose of this essay is to highlight and discuss on the issues of work life conflict & how it affects further to discuss about the solutions that could be applied to tackle the conflicts. Secondary researches have been used in order to support the discussion in an effective way.

2.0 Causes

2.1 Women’s Family Commitment

Over recent years there has been an enormous increase in the number of women employees entering to the paid workforce labor of Hemas Hospital Wattala. Despite the rapid growth in women’s involvement in the paid workforce; it appears that little has changed for women in terms of their family commitments.

Culture plays a big role in Sri Lanka in relation to this topic. “Traditional gender roles prescribe for women to place the role of wife and mother above all others; men are expected to be the family breadwinner. Given the burden of household responsibilities and child care, women employees (doctors, nurses, receptionists) face the demands of multiple roles, which often go beyond the general three roles working mothers generally take on (wife, mother, and worker) to include responsibilities such as: caretaker of aging parents, sister, aunt, cousin, etc.” (Scott Coltrane, n.d.)

As a result of these multiple tasks work life conflict has been identified as a common problem among most women employees at Hemas Hospital.

2.2 Personal Health Problems

Health is the general condition of a person in all aspects. Having problems is a part of life. Most of the researches have found that effects of stress affect the health. The reason is the stress and health is closely linked. And also they have found that the risk factors for health caused by chronic stress causes as much as 60 to 90% of all illnesses. The impact it has on your health, both physical and mental, can be very harmful. And individuals stress does contribute to high blood pressure, high cholesterol, and other cardiac risk factors such as addictions and obesity. We found that 55% of Hemas hospital’s nurses getting sick because of the stress they have. Some of the shifts they have to cover up without taking breaks. Therefore they cannot balance their personal lives with the work they have. So that stress arises and automatically they get ill.

2.3 Tight Work Schedules

Workers have to control their working hours to enjoy a better life. Most of time nurses have to do night duty and also they have to do over time work because of this reasons lack of flexible working hours can be arising. Most of times who worked as nurses are young mothers so then they have do their children work, they have to care about children and also their home work. It is very hard to do night duty person who has small child then they might feel time is more important than money after that there can be arise a stress on work place. Organization culture can shape the work life balance. According to our culture most of time mothers are house wife’s and also children’s need care of mothers. If mother busy with her job then there will be arises social problem and also family problems. In Hemas hospital every nurse has to do two night duties in each week and then there arises conflict between work life balances.

2.4 Lack of Employee Rewards and Appreciation

As a nurse Caring for the sick and dying has never been easy. Though it is a respected, intellectually stimulating, and deeply meaningful career today it offers limited benefits and many challenges.

Though it’s been 2 years Hemas Hospital started their management hasn’t introduced proper rewarding system for the nurses. This will directly affect the employee’s morale; therefore employee productivity would be less.

2.5 Transportation Issues

Transportation is one of the main issues that Hemas Hospital employees are facing. Since there are both day and night shifts, the employee’s main problem will be the transportation.

In Sri Lanka with the cultural situations most of the people think in negative way when the females doing the night shifts and/or when they arrives at home in mid night, Since the public transportation is not too safe for female after around 7.30 – 8.00 pm the transportation will be highly regarded when comes to night shifts.

3.0 Effects

3.1 High Absenteeism

Absenteeism is an expensive problem in both public and private sector organizations. Over the past decade, there has been increasing interest in the impact of women’s family responsibilities, personal health problems and transportation problems on absenteeism. Many women employees at Hemas Hospital find it hard to achieve their desired combination of work and family time. For example, family responsibilities appear to constrain a woman’s choice of occupation. Women taking leave due to illnesses of children or their elder parents.

3.2 Less productivity

Due to personal health problems, lack of rewards and appreciations and tight work schedules employees’ productivity getting reduced. This situation is not good for a working place like hospital. Productivity is one of the most important factors when it comes to work. When employees are not healthy they are unable to work properly. Therefore their productivity comes down and the job they do cannot be performed properly. When working in a hospital, the employees have to work very effective manner, because they are the savers of patients’ lives. It will be a big disaster if they forget or neglect to give proper medicine or giving wrong medicine to a patient. This would highly affect to Hemas hospital if they do not work properly up to the standard.

3.3 Dissatisfaction

“While the majority of “reasons” for dissatisfaction usually point to elements of the workplace itself such as: management style, environmental conditions or opportunities for growth, lack of rewards and appreciations, tight work schedules etc.” (“A guide to grow your personal growth”, n.d.).

It was found that especially nurses are dissatisfied with their job. Due to this they may move towards competitors or leave the job. Therefore Hemas Hospital has to consider ways of minimizing the work dissatisfaction.

3.4 Stress

Stress is the most hated part of the job of healthcare employees. This can be occurring due to personal health problems, women’s’ family commitments and tight working schedules. Therefore it leads nurses to be dissatisfied with their work. Due to the dissatisfaction they will not perform efficiently and effectively through less performance. Furthermore their loyalty for the company will be less and will tend to move towards competitors or leave the job.

One of the respondents at the Hemas hospital said that, “Too much pressure on this shift… Scanty facilities… very meager…you feel really exhausted…amounting to tensions and conflicts which are often displaced onto people around…you know…yelling at colleagues…”

3.5 High employment turnover

This can be happened due to all of the causes mentioned above. More than the cultural influences nursing is a more stressful and challenging job therefore it’s a must to recognize them as very precious for the hospital to make them retain in the hospital. The impact of turnover has received considerable attention by senior management, human resources professionals, and industrial psychologists.

It has proven to be one of the most costly and seemingly intractable human resource challenges confronting organizations. Analyses of the costs associated with turnover yield surprisingly high estimates. The high cost of losing key employees has long been recognized. When consider the Hemas Hospital the situation also same. It appears high employment turnover, especially nurses.

3.6 Work overload for other employees

Due to health problems and family commitment some employees cannot perform their duties to the expected level. So others will have to carry out the sick employees work load too. Some times since they haven’t time to fulfill the work load they might not do even their assigned duties properly. They do not care about the patients very well. Then again it will affect to the overall performance of the Hemas hospital.

In addition, inadequate facilities, improper functioning of other employees and neglected responsibilities created pressure and conflict among the personnel. These inadequacies eventually reduced the tolerance threshold, which in turn contributed to the conflict experienced.

One of the respondents at Hemas hospital said that, “We can’t ignore the fact that heavy workload and shortage of skilled human resources affect our performance; despite our effort to get used to the situation, we are limited in coping. When you see that the supervisor stops backing us up and never steps into the ward to listen to us it makes us feel our rights have been violated.”

4.0 Solutions

4.1 Paternity leave

Paternity leave is the time a father takes off work at the birth or adoption of a child. This kind of leave is rarely paid. A few progressive companies offer new dads paid time off, ranging from a few days to a few weeks. Hemas Hospital can arrange paternity leave for doctors and therefore can avoid the absenteeism and dissatisfaction towards the job.

4.2 Dependent care arrangements

Many nurses will be faced with issues of child or adult care giving. Without adequate support, these can create a host of distractions from work. There are many ways that the Hemas Hospital can support their nurses with their personal responsibilities. Some of the ways are on or off site child and adult care centers, lactation programs, dependent care referrals, etc.

4.3 Job sharing

Job sharing is a form of permanent part-time work in which a full-time position is divided between two or more people, each of whom shares responsibility for the entire workload. Each job sharer receives conditions of employment and entitlements on a pro-rata basis in proportion to the hours worked. Job share arrangements are suitable for both professional and academic positions. A change from full-time work to a job sharing arrangement does not break continuity of employment.

Job share arrangements can facilitate increased workplace flexibility because job sharers can relieve or cover for each other without loss in efficiency and effectiveness. Hemas Hospital also can implement this program and can get the maximum benefit out of it.

4.4 Flexible work schedules

A flexible work schedule is a type of flexible work arrangement that allows employees to vary when they begin and end their work day to accommodate their individual and family needs. This flexibility greatly eases the burden of busy employees as they try to juggle their work and home lives Flexible work schedules benefits both employees and organization it self.

For employees Increased satisfaction and productivity, reduced stress and health care costs, decreased absenteeism and reduced commuting time. For organizations improved retention and reduced turnover, higher levels of loyalty and commitment ,no change in manager’s supervisory time, attracts diverse employees who may not be able to conform to rigid schedules (i.e., disabled)

4.5 Incentives

As a result if the hospital is not rewarding nurses well the Sri Lankan culture influences them to be not loyal towards hospital and as well to perform poorly. If an employee appreciated or rewarded it will influence them to work hardly than the before and also motivate to keep the work and personal life in a balance. For that reason this is the best time for Hemas to start an appropriate rewarding and appreciation system for their nurses to make them satisfy and happy situation between work and life.

5.0 Recommendations

5.1 Short Term

Out of the number of solutions available, according to the situation, a strategy needs to be developed according to the problem but this would consume lots of time and energy to be done, So till a proper strategy is developed, in the short term the hospital can reward employing workers with an incentive programmed to facilitate them to balance their work /life.Hemas Hospital can reward financial non financial incentives to encourage their work force. Under financial incentives they can grant child vouchers and can have a special funding system for employees’ children. Furthermore the management of Hemas Hospital can introduce a transportation allowance system for the employees who come from distance areas. Under non financial incentive system Hemas Hospital can arrange family friends’ benefits or annual trips or get together, so that they have sometime to spend their leisure time with their colleagues. Furthermore nurses can be given promotions, scholarships or they can select best nurse annually to encourage nurses.

5.2 Long Term

But in the long term proper strategy should be developed to address this problem, because incentives cannot be a solution for all the problems of the employees. While developing strategies the different situations of nurses need to be considered to facilitate them. Providing a flexible work options is a good method that could be developed, because job satisfaction is directly connected to a persons work schedule, especially to a nurse’s healthy mentality it is very important when dealing with patients.

“A variety of schedule options could be made available to fit their priorities and life styles.

Full-time

Options include:

Three 12-hour shifts

Five 8-hour shifts

A combination of 8 and 12-hour shifts

Part-time

Options include:

8-hour shifts

12-hour shifts

A combination of 8 and 12-hour shifts

Weekend Program

This program is an appealing option for nurses who are in school or who care for children during the week. This option provides short-term disability coverage.

Weekend nurses work 24 hours each weekend

They receive pay equivalent to 32 or 36 hours

The schedule begins Friday at 7:30 a.m. and ends Monday at 7:30 a.m.

Casual

This option is appealing to nurses who want to work fewer hours but maintain a relationship with their unit and with Northwestern Memorial Hospital.

Casual nurses work 40 hours during a 6-week schedule

Float Pool

Nurses may choose the flexibility and variety of working on multiple units through the Float Pool. Float Pool nurses are required to work two weekend shifts per month.

Options include:

Full-time work

Part-time work

Dynamic scheduling to accommodate personal work requirements.

Schedule Choices

Many nursing units offer nurses a Self Schedule option. They are able to select the days on the upcoming schedule they want to work. When their manager creates the schedule, he or she will balance the schedule requests with current patient needs in the unit” (“Careers”, n.d.).

The best recommendation would be to make available lots of flexible work schedule options and offer the nurses with a self schedule option, so that they can use choose a schedule according to their life style. These work options should be for the mutual benefit of both the employee and the employer so that employee can fulfill their responsibility towards their work place and as well as their families.

6.0 Conclusion

There is a big difference between doing things and getting something done. Most work-life efforts by HR and work-life balance teams fail despite lots of doing. The problem is that all the doing didn’t get anything done.

If the organization wants to get something done that produces strong positive results and feedback, it should be start by taking an action in order to ensure success. Good work-life balance seems to be something that well-run firms in competitive markets do naturally. They need to treat their employees well to keep them – if not; their competitors will hire them away. Government policies on work-life balance should take this into account.

Whether the organization just introducing a work-life program or making an already great one better, the organization will be substantially improving its bottom line results and changing individuals’ lives for the better. To be an effective worker he/she has maintain a better balance in between work life and the personal life. We can see that there is a clear link between causes for the conflicts and effects of them. So that if Hemas can implement the above mentioned recommendations we think that Hemas can be the best hospital by getting the maximum use of their employees while providing them a conflicts free work life environment. Hence the entire organization and employees will be proud of the results.

The “Greying of America”, refers to the endurance in our seniors which is tugging on all the resources in our society. People are living longer healthier lives. This is a good thing and a bad thing. Are we ready to meet these demands on our society in the long term? Some believe this will be a financial burden on Medicare, long-term care, public pensions and financial programs.The aging population has multiple facets; including the financial, physical, emotional, and psychologicalneeds represented in society. There is increased question if our Social Security and Medicare System will hold out to care for this generation.How will supply and demand be met when there are fewer in the work force? How will the money in Social Security System last, when less is being put in? “A large population of the United States is old and non-working. Almost 24 percent of the population in US is over 50 years old.” http://www.naswdc.org/pressroom/features/issue/aging.asp

Officials refer to this changing time in our history as the “Greying of America”.

For a long time over population was stated in our country and others, like China. One child in China and in the United States two children were plenty, now, it seems the baby boomer generation will be the largest demographic, the older generation. Some of the baby boomers have already reached this time in their lives. Baby Boomers were born in the years 1946 to 1964. If you do the math those born in 1946 are now 67, which is retirement age or it was. Retirement age used to be 65, but as the demands on our economy, so the retirement age is pushed back. Some say 72 is the new retirement age.“Statistics project that by 2030, Americans 65 and older will actually outnumber their younger counterparts. With the aging of the “baby boomer” generation and the lengthening of life spans, both the number and proportion of older people are rapidly increasing. Many of the health related problems that contributed to decreased life span have been combated”.

http://www.naswdc.org/pressroom/features/issue/aging.

Another question is housing, some live in their homes, assisted living, nursing homes or independent living, but will there be enough structure in place to meet these growing needs? There are also the needs of the families, caring for their elderly parents, while raising their children, and working. An article written by Joan Mooney, “Housing America’s Graying Population, she states: Eighty to 90 percent of Americans want to “age in place,” either in their current home or in their neighborhood. But most homes and communities are not set up to house the elderly. And also in an interview with Henry Cisneros, former Hud Secretary, he stated, “The solution will lie not just in individual homes, but also in the surrounding communities. The number-one fear of people as they age is isolation,” said Cisneros. “They need to be able to get to the doctor, stores, parks, and other public amenities” (Mooney).

http://urbanland.uli.org/infrastructure-transit/housing-america-s-graying-population/

Another area of concern, are the growing needs for professional social workers for this demographic in our society. Will there be enough workers for all the needs characterized by this growing segment? Social workers serve as advocates for the older people and their families, providing necessary connections for the services needed. As these demographics change and grow there is a growing requirement for social workers to provide for the necessities of these individuals and their families. There are also questions about how this generation will be taken care of since the largest part of the population will be older, and less will be in the market place.

Social workers are essential to this growing segment in our population. The professional, skilled social worker, who is equipped in problem solving, can lend peace, security and hope to the individual. They are knowledgeable about how human behavior, social, financial, and cultural issues, and how they relate and affect daily lives. So, as there are economic factors that lead to nervousness about the future of our economic growth. There are also valid arguments for supply and demand. Yes there are possibly less workers in the work force, though people are working longer. There are new or growing markets for healthcare, housing, social work intervention and pharmaceuticals, among other things that will drive the economy. There is definitely going to be cause for growth in the Gerontology field. Currently this is not an area, where social workers tend to stay due to financial restrictions, among other things. In a testimony given by:

Testimony of Elizabeth J. Clark, PhD, ACSW, MPH Executive Director, National Association of Social Workers Washington, DC Submitted to the Special Committee on Aging United States Senate Hearing

She advocates encouragement, incentives for people to enter the social work arena for the elderly through providing education, and stronger rewards to gain retention in an area of service where the general social worker does not feel it is advantageous. Otherwise the shortages will be acute and lacking the professional

Worker needed to avoid a dangerous outcome, for the coming era. She also advocates education and marketing to avert the common ideas that are related to working with older generation. That it is depressing working with the sick and the dying. A perception also exists that there are few personal, professional, and societal rewards for working with older people.

Social Workers need to take an aggressive approach to change the opinions that older individuals lack value, these needs to change in the hearts of Americans and in the hearts of the people reaching this age.

It is also concluded, NASW agrees that the existing health care workforce will be inadequate to meet the needs of older Americans. They believe the Federal Government should be involved and encouraged towards loan forgiveness, stipends for students and faculty, and financial support for field placements in geriatrics to be able to attract and retain social workers and other health care professionals in the field of geriatrics.”

The reason I include large portions of this article is I believe that will support and show this so-called Greying America does not have to be a problem. It can be solved through its own counterparts. We the nation and the other surrounding developed nations can use their own resources with the help of professionals. With encouragement, marketing, education and direction people can live functional lives even in old age.

As the baby boomer generation is different in a variety of ways, this can add enthusiasm to the discussion because, this generation does not want to stop and sit in a rocking chair. Yes, as boomers age, they will put increasing burdens on the health care and financial system. There is proof that there is a shortage in practitioners in the area dealing with aged population. And there is proof that medical advances have taken place due to this encroaching segment in the population. The fact that the older generation is trying to stay younger through exercise and prevention and taking care of themselves is causing innovation in the medical industry.

It has been said that many core nations are working toward and getting honestly prepared for the rise in the elder population. There is always the concern for the impoverished segment, like elderly, single women, and some minorities that are on the fringes. But that is where the social worker can be a benefit, searching for crucial answers and direction, and educating society to the benefits age can provide, so the stereotypes can change and empower the elderly, especially in their own attitudes.

The cultural views on aging have changed also. Before this age, before the industrial revolution, our elders were given great respect. The family included the elders, grandparents in the home. They helped raise the grandchildren and provided wisdom in the home. But cultural views have changed and the older population doesn’t seem as necessary or crucial to the family and the world. The stereotype of the older population depicts them as old and feeble, they are a drag on society, in their usefulness and value. In many cultures the elders were revered and needed now they are replaced by youthfulness and vigor. They are shuffled off to nursing homes instead of being an integral part of the home.

There is great concern over finances, will our economy survive when varying resources are changing. Coming from the perspective of belonging to the ‘baby boomer generation and reading various articles, this generation was a change from previous generations. There was an increase in money to be spent and less saved. There became more emphasis on pleasure and leisure. After the depression, the financial world allowed for more to be had, with a blink of an eye. You did not have to save, before buying as our parents did. So, is this generation ready to quit the market place? Many are working longer due to the need to save and get out of debt. This can be a good thing as working enriches lives, keeps the brain sharp and hopefully the body more nimble.

So this is cause and effect, our society is living longer, less population, so we now have to control the somewhat adverse effects of an older population? Or is it an adversity? Are older people nonproductive residues in our environment? Maybe because I am a part of that generation, I believe they have contributions, yet to give. Mother Theresa was older when she passed from this world. Should she have been pushed into a corner to die? I do not believe so. She was a great asset to the community in our world. My mother, until recently resided in our home for years. Now she is in Oregon with the rest of my family, but she is valued and loved. I do not think people intend to relegate the elderly to the corner, but pressures in the home, finances and social perspective seem to guide us there.

The Social Work profession wants to work to change these notions and show people their worth, through, information, education, counselling, community assistance and many other problem solving community and government actions. What can be done to change the present outcome? We need to let people continue to contribute in their own way, so they can feel their worth. Yes, generally they cannot move as fast, even think or talk as fast as you or I. But they can show and teach us, if we are willing to learn and listen. We have learned by studying History that we can change things and have a better outcome for the future if we do not repeat mistakes. I believe when families co-existed, the family unit had a greater strength and fortitude to weather storms. Culturally, the breakdown of the family unit exists, but the foundations can still be built through relationships and assistance to the needy. Through reaching out in the community, and again this can be directed with social assistance. Social workers in this environment are trying to instill life in the elder patient and the family giving them direction, and assistance through the transition, of being the giver to the receiver as an older person is. But we can still allow them to give through their lives, if we are willing to receive.

Working in the public, networking, people are not satisfied to stop at a certain age, but press on to learn new things. There are many people re-inventing themselves at different walks in their lives, to allow for change, challenge and growth as individuals, who will benefit society. This benefit can come in the form of financial advantage and socially for our society as a whole to counter affect the challenges of a so-called decaying society. With encouragement, marketing, education and direction people can live functional lives even in old age.

Sources

Gibelman, M. (1995). What Social Workers Do (4th ed.). Washington, DC. NASW Press.

Dunkle, R.E., Norgard, T. (1995). Aging Overview. In R.L. Edwards (Ed.-in-Chief), Encyclopedia of Social Work (19th ed., Vol. 1, pp. 142-153). Washington, D.C.: NASW Press.

Zuniga, M.E. (1995). Aging: Social Work Practice. In R.L. Edwards (Ed.-in-Chief), Encyclopedia of Social Work (19th ed., Vol. 1, pp. 173-183). Washington, D.C.: NASW Press.

This assignment will look issues around older people’s mental health, in particular, dementia and abuse; this will include demographics of older people, statistics, the history, definitions and causes of dementia, and finally the lack of legislation to protect vulnerable people from harm and the implications for social work practice.

The population surge at the end of world war 2 has gave rise to an unprecedented population explosion and to what we now call the ‘baby boomers’, these people are now in their retirement years'(Summers Et al, 2006), and our population now contains larger percentage of older people that ever. In society today elder people are becoming the fastest increasing population in the UK, National Statistics (2009) states that ‘the population of the UK is ageing. Over the last 25 years the percentage of the population aged 65 and over increased from 15 per cent in 1983 to 16 per cent in 2008, an increase of 1.5 million people in this age group’. Due to the increase of the ageing population we are now seeing emerging health and social care issues in our society. Many older people will be active, involved within the community, and independent of others. However, as you get older it is natural to experience pain, a decline in mobility or mental awareness.

Mind (2010) states that ‘the most common mental health problems in older people are depression and dementia. There is a widespread belief that these problems are a natural part of the ageing process, but this not the case; it can start as early 40 but is more common in older people (Royal college of Psychiatrists, 2009), however, ‘there only 20 per cent of people over 85, and 5 per cent over 65, have dementia; 10-15 per cent of people over 65 have depression’ (Mind, 2010). It is important to remember that the majority of older people remain in good mental health. ‘Dementia mainly affects older people, although it can affect younger people; there are 15,000 people in the UK under the age of 65 who have dementia’ (Alzheimer’s society, 2010). However, ‘currently 700,000 – or one person in every 88 in the UK – have dementia, incurring a yearly cost of ?17bn, and the London School of Economics and Institute of Psychiatry research calculated that more that 1.7 million people will have dementia by 2051’ reported by BBC news (2007).

‘The word dementia comes from the Latin ‘demens’ meaning ‘without a mind’. References to dementia can be found in Roman medical texts and in the philosophical works of Cicero. The term dementia came into common usage from the 18th Century when it had both clinical and legal connotations. Dementia implied a lack of competence and an inability to manage one’s own affairs. Medical use of the term dementia evolved throughout the 19th century and was used to describe people whose mental disabilities were secondary to acquired brain damage, usually degenerative and often associated with old age’ (Kennard 2006). From the 20th century onwards scientific knowledge was supplemented through the examination of the brain and brain tissue which was founded and performed by a physician Alois Alzheimer (Plontz, 2010). The National service framework (Department of Health, 2001, p96) now defines ‘dementia as a clinical syndrome characterised by a widespread loss of mental function’.

The term ‘dementia’ is used to describe the symptoms that occur in a group of diseases that affect the normal working functions of the brain. This can lead to a decline of mental ability, affecting memory, thinking, problem solving, concentration and perception, also problems with speech and understanding (Mind, 2010). ‘Dementia is progressive, which means the symptoms will gradually get worse. How fast dementia progresses will depend on the individual. Each person is unique and will experience dementia in their own way’ (Alzheimer’s society, 2010). Symptoms of dementia include: Loss of memory, Mood changes, and Communication problems. In the later stages of dementia, the person affected will have problems carrying out everyday tasks, and will become increasingly dependent on other people, two thirds of people with dementia live in the community while one third live in a care home (Alzheimer’s society, 2010). There are many types of dementia, and some of the causes of dementia are rarer than others, Alzheimer’s disease is the most common cause, damaged tissue builds up in the brain to form deposits called ‘plaques’ and ‘tangles’, these cause the brain cells around them to die (Royal college of Psychiatrists, 2009). Other most commonly known is vascular disease, Dementia with Lewy bodies, Fronto-temporal dementia. Mostly, patients themselves do not present to the clinician with dementia, owing to gradual onset and denial of the problem. There is no cure for dementia but there is medication that will help to slow down the progression of the disease. When finding help for dementia it is usually the primary carers, caregivers, supporters, partners or family members who initiate asking help and a diagnosis (Brodaty, 1990).

Depression may be misdiagnosed as dementia the difference being that people who have depression are more likely to be aware of their issues therefore are able to discuss them, whereas someone with dementia may not be able to do this due to their symptoms. Nonetheless, the Mental Capacity Act (2005) states that every person has the right to make their own decisions and must be assumed to have capacity unless otherwise proven and people should be supported to make any decisions. Under the MCA, you are required to make an assessment of capacity before carrying out any care or treatment (Office of the public guardian, 2009). The Mental capacity act is an act that protects individual rights and ensures that the person’s liberty is not taken. ‘It is based on best practice and creates a single, coherent framework for dealing with mental capacity issues and an improved system for settling disputes, dealing with personal welfare issues and the property and affairs of people who lack capacity. It puts the individual who lacks capacity at the heart of decision making and places a strong emphasis on supporting and enabling the individual to make their own decisions’ (Office of the public guardian, 2009). However, even with a structure in place to protect individual’s rights and liberties many people who have dementia are more vulnerable to abuse due to their lack of capacity. The University College London research revealed that a third of carers admitted “significant abuse”, in total 115 carers reported at least some abusive behaviour, and 74 reported more serious levels of mistreatment (Cooper et al, 2009). Caregivers can also be on the receiving end of verbal or physical abuse directed at them by parents or spouses who are confused and angry over declining mental capacities due to stroke and Alzheimer’s disease. In some cases, Alzheimer’s disease or other forms of dementia may cause the patient to be uncharacteristically aggressive (Coyne, 1996).

It is only in recent years that abuse of the elderly has become more apparent, Crawford Et al (2008, p122) argues that over time it has very slowly come to the attention of people in the last 50 years that abuse does actually exist behind closed doors; in the 1950’s older people lived in large families where issues were hidden, and in the 60’s to 70’s older people started living alone or in residential homes and it was not until the early 80’s that abuse had started to be recognised and defined. Penhale and Kingston(1997) argue that over the years it has been difficult to emphasise the issues of abuse due to not finding a sound theoretical base to which an agreement of a standard definition can be made and applied. Action on elder abuse (2006) defines elder abuse as ‘A single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person’. Abuse comes in not just physical abuse it comes also in sexual, psychological, neglect, discrimination and financial as well. ‘Older people may be abused by a wide range of people including family members, friends, professional staff, care workers, volunteers or other service users, abuse can also be perpetrated as a result of deliberate, negligence or ignorance’ (Royal pharmaceutical society (RCA), 2007). Abuse can occur in a variety of circumstances and places such as, in own home, in a residential or day care setting or hospital and can by more than one person or organisation. Pritchard (2005) asserts that we will never have a true picture of the prevalence of elder abuse due to the unreported cases, and can only count ones that are known to organisations and services.

Most abuse is still unreported due to victims being frightened, ashamed and embarrassed to report the abuse, not realising their rights or not being able to due to tier mental health. Summers et al (2006, p7) points out that ‘those statutes that make abuse criminal are often ineffective due to them not being utilised by the victim’, and this means that this will be the biggest challenge and barrier for change in getting people to recognise the scale of the problem and raising awareness so that the government agree to change the legislation to protect older people. Abuse of any kind should not be ignored and there should be legislation to protect adults from abuse like there is in child protection, people who recognise the extent of elder abuse argue why should adults be treated as second class to children, is their suffering and deaths any less important? The Alzheimer’s Society (2010) states that ‘abuse of people with dementia should be considered in the same way as child abuse’.

Crawford and Walker (2008, p12) state that ‘prejudice refers to an inflexibility of the mind and thought, to values and attitudes that stand in the way of fair and non judgmental practice’. Thompson (2006, p13) defines discrimination as the process in which difference is identified and that difference is used as the basis of unfair treatment. A barrier to recognising the abuse of people with dementia and older people is that of social stigma, negative perceptions and connotations of words for mental health, such as confused or senile. ‘Confused is something that we all experience at some time in our lives, whereas senile is a more complex word and the first recording of its usage was neutral meaning pertaining to old age, but now has negative connotations linked to mental decline due to age (Crawford and Walker, 2008). Therefore, challenging people’s perceptions needs to done to change these social constructs to enable a change in legislation and protection of vulnerable adults. In March 2010 the department of health ran a series of campaigns to address poor public understanding of dementia which included TV, radio, press and online advertising featuring real-people with dementia (Department of health, 2009).

In 2009 the first ever dementia strategy was launched that hopes to ‘transform the quality of dementia care, It sets out initiatives designed to make the lives of people with dementia, their carer’s and families better and more fulfilled It will increase awareness of dementia, ensure early diagnosis and intervention and radically improve the quality of care that people with the condition receive. Proposals include the introduction of a dementia specialist into every general hospital and care home and for mental health teams to assess people with dementia’ (Department of health, 2009). However, this is not legislation it is just a strategy for dealing with people with dementia. The government are recognising that there is little protection for vulnerable adults and that further legislation need to be put in place and stating that dementia care is a priority (BBC news, 2007). At present, there is no one specific legislation which directly protects vulnerable adults, instead the applicable duties and powers to assess and intervene are contained within a range of legislation and frameworks, such as the Mental Capacity Act 2005 and Mental Health Act 2007 and the national service framework for older people. ‘One of the themes for national service framework (NSF) is respecting the individual which was triggered by a concern about widespread infringement of dignity and unfair discrimination in older peoples access to care. The NSF therefore leads plans to tackle age discrimination and to ensure that older people are treated with respect, according to their individual needs, specifically in standard 2 it relates to person centred care ‘ (Crawford and Walker, 2008, p8).

And expectation of NSF is that there must be systems and processes put in place to enable multi agency working. In 2000 the government published ‘No secrets which is guidance that requires local authorities to set up a multi agency framework which includes health and the police with a lead person (adult social care) to carry out procedures into the allegations of abuse whilst balancing confidentiality and information sharing’ (Samuel, 2008). No Secrets is only ‘guidance and does not carry the same status as legislation, the LA’s compliance is assessed through an inspection process, therefore the LA can with good reason choose to ignore the guidance’ (Action on elder abuse, 2006). This has concerned agencies who want to see the protection of adults given the same equivalent priorities as child protection and think that legislation is the only way to accomplish this.

A review of No Secrets guidance has been carried out in 2008 and consulted with over 12000 people (Department of Health, 2009), the report found that over half (68%) of the respondents were in agreement to new safeguarding legislation and 92% wanted local safeguarding boards to be placed on a statutory footing and still there is no legislation to protect vulnerable adults (Ahmed, 2009). A recent article in community care told the failure of the government to commit to making a policy has only strengthened campaigners fight and given rise to criticism (Ahmed, 2009).

The need to protect vulnerable people brought about the protection of vulnerable adults scheme (POVA) which is run by the Department of Health to regulate and monitor the employment of staff in the social care workforce, through this scheme a list of people who are unsuitable to work with vulnerable people is kept. More recently, the Safeguarding of Vulnerable Groups Act 2006 which was launched in 2008 replaced POVA with the Independent Safeguarding Authority (IDeA, 2009). The problem with this is that abusers of dementia sufferers are usually family member or informal carer that are under considerable stress and may not receiving help from within the health and social care system, therefore, an abusive situation can carry on for some time until the situation is found by an outsider. This situation may only be found when a informal carer starts asking for help, and when informed of the situation it is good practice and essential to make sure that carers are getting the help they need which can prevent the abusive situations. Under the 1995 Carers (Recognition and Services) Act carers are entitled their own assessment of need and by doing so this may allow for respite or payments to be made for their services (Parker Et al, 2003). University College London researchers who interviewed people caring for relatives with dementia in their own homes stated within their research that ‘Giving carers access to respite, psychological support and financial security could help end mistreatment’ (Cooper et al,2009). When working with relatives who are carers it is important to remember who is the service user, although it is important to ascertain the wishes of the relative it should not override the wishes of the service user, this is especially true when there is a break down in the care of the service user and the carer wishes the service user to be placed in care.

Many older people with dementia receive care in a residential home; this may be due to family member no longer being able to cope with the care of the person. The local authority has a duty to assess the needs of a person with dementia ensuring that their wishes are heard and adequate care is put in place. ‘Assessment is an ongoing process, in which the client participates, the purpose of which is to understand people in relation to their environment; it is a basis for planning what needs to be done to maintain, improve or bring about change in the person, the environment or both’ (Anderson Et al, 2005).

The trouble with placing people with dementia in care homes is there are not enough care homes specifically for people with dementia and people end up in a home that do not have trained staff to cope with individual needs of someone with dementia, therefore, people s wishes may not be heard. As part of the joint assessment process it is the social workers role to ascertain the wishes of the individual, this is done by assessing their needs in an holistic way which includes and medical and social aspects of the person. If there is doubt as to the mental capacity of the person then a mental capacity assessment will need to be acquired by asking to joint assess with community psychiatric nurses (CPN). Priestley (1998) states that ‘the community care reforms established the principle of joint working between health and social services authorities as a priority for effective care assessment and management with social services taking the ‘lead role’.

In conclusion there seem to have been many shifts in the direction of how policy and procedures framework and guidance care for people with dementia, although there is still no firm legislation to protect them. However, there seems to be more recognition of the issues that surround dementia and future goals are towards the training of people to understand those issues so that professionals are able to deal with the complex needs of a person with dementia.

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This essay will discuss the complex issue that is self harm in society today; although word count will restrict many of the areas this essay will try and achieve an overall balance. The essay will look at the psychological causes and treatments available to service users via the National Health Service. It will be necessary throughout the essay to compare the issues surrounding self harm with that of parasuicide and suicide itself. Consideration will also be given to the views and perspectives of the service user with regard to the service they receive and where appropriate this essay will refer to practice experience to provide depth and insight into aspects of the discussion. Reference will also be made to the links with self harm in the animal kingdom. This brief discussion with animal self harm will be an attempt to show dual causation in humans and animals. Highly concise introduction, well done.

In order to better understand self harm this issue must be clearly defined as to avoid inaccurate and misleading terminology as self-harm covers a wide range of behaviours some of which are directly related to suicide and some are not. Self harm (SH) or deliberate self harm (DSH) including self injury (SI) and self poisoning (SP) is defined as the intentional direct injury of body tissue without suicidal intent (Laye-Gindhu, A 2005., Klonsky, E.D 2007., Muehlenkamp, J.J 2005). Self harm is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-1V-TR) (1994) as a symptom of borderline personality disorder. However, patients with other diagnosis may also self harm including those with depression, and anxiety disorders, substance abuse, eating disorders post-traumatic stress disorders, schizophrenia and several personality disorders. Self harm is also apparent in high-functioning individuals who have no underlying clinical diagnosis. (Klonsky, E.D 2007). Guidelines for the treatment of self harm are not specified from NICE.

What is self harm, self harm is deliberate damage of the body that is intentionally not life threatening, often repetitive in nature and usually considered socially unacceptable, 80% of self harm involves stabbing or cutting the skin with a sharp object (Greydanus, & Shek, 2009). It is generally agreed that someone does not intend to die as a result of his or her self harm. However, many acts of self harm are not directly connected to suicidal intent they may be an attempt to communicate with others to influence or to secure help or care from others or a way of obtaining relief from it difficult and otherwise overwhelming situation or emotional state (Hjelmeland et al., 2002). Walsh and Rosen (1998) in discussing the difference between self mutilation and parasuicide have noted; “In the case of ingesting pills or poison, the harm caused is uncertain, unpredictable, and basically invisible. In the case of self lacerations, the degree of self harm is clear, unambiguous, predictable as to course, and highly visible” (Walsh, B.W., Rosen, P.M 1988). However someone who self harms is 50-100 times more likely to attempt suicide than someone who does not (Martinson, D. 1998).There are many reasons why people self harm, in a survey conducted of young people aged 16 through to 25 the most common reason was “to find relief from a terrible situation” (Samaritans 2001).Self harm is often associated with a history of trauma and abuse including emotional abuse, sexual abuse, drug dependence eating disorders or mental traits such as low self-esteem or perfectionism. (Swales, M. 2008)

Emotionally invalidating environments where parents punish children for expressing sadness or hurt can contribute to a difficulty experiencing emotions and increased rates of self harm (Martinson, D. 2002). Abuse during childhood is accepted as the primary social factor as is bereavement, and troubled parental or partner relationships. Factors such as war, poverty, and unemployment may also contribute. In addition some individuals with pervasive developmental disabilities such as autism engage in self harm, although whether this is a form of self stimulation or for the purpose of harming oneself is a matter of debate (Edelson, 2004)

It is noted that Service users who self harm give broadly three reasons for their behaviour these are, controlling mood, regulating moods in terms of how a person is able to cope with emotions and feelings especially feelings which are particularly unsettling unpleasant or intense. Communication, some people use self harm as a way of expressing themselves if those expressions are directed at others this can be seen by some as attention seeking and manipulation. Understand in what an act of self harm is trying to communicate can be crucial to dealing with it in an effective and constructive way. Control/punishment, people who self harm have often experienced traumatic experiences in their lives including emotional physical or sexual abuse. (Martinson, D. 1998). Self harm can be a form of trauma re-enactment or way of bargaining or engaging in magical thinking “if I hurt myself I will prevent the thing I fear protect the person I care about”. A common belief regarding self harm is that it is an attention seeking behaviour however in most cases this is inaccurate. Many self- harmers are very self-conscious of their wounds and scars and feel guilty about their behaviour leading them to go to great lengths to conceal their behaviours from others (Mental Health Foundation 2006).

People diagnosed as having certain types of medical disorder are much more likely to self harm in one survey of a sample of the British population people with current symptoms of mental disorder up to 20 times more likely to report having harm themselves in the past (Meltzer et al., 2002).People diagnosed as having schizophrenia are most at risk and about one-half of this group will have harmed themselves at some time. When assessed the majority of individuals engaging in self harm will be diagnosed with depression although two thirds will no longer fit the criteria after a year. This explains why nearly half of those who present to an emergency department meet criteria for having a personality disorder (Haw et al., 2001). However, there are problems with doing this because some people who self harm consider the term personality disorder to be offensive and to create a stereotype that can lead to damaging stigmatization by social care workers (Babiker & Arnold, 1997., Pembroke, 1994). About one in six people who attend an emergency departments following self harm will harm themselves again in the following year (Owen et al., 2002).

For the last 25 years it has been NHS policy that everybody who attends hospital after an episode of self harm should receive a psychological assessment (Department of Health and Social Security, 1984).While psychological assessment includes several components, the most important are the assessment of needs in the assessment of risks. The assessment of needs is to each item to identify those personal (psychological) and environmental (social) factors that might explain an act of self harm; this assessment should lead to a formulation, based upon which a management plan can be developed. Despite the importance of comprehensive assessment following an act of self harm many service users “fall through the net”. In many hospitals, more than half of the attendees are discharge from the emergency department without specialist assessment (Termansen & Bywater, 1975; Thomas et al., 1996; Kapur et al., 1998). Patients who leave hospital direct from an emergency department and especially those who leave without a psychological assessment are less likely to have been offered to follow- up (Owens et al., 1991; Suokas & Lonnquist, 1991; Gunnell et al., 1996; Kapur et al., 1998). In addition, those who do receive the psychological assessment (rather than the needs or risk assessment specifically) may be less likely to repeat an act of self- harm (Hickey et al., 2001; Kapur et al., 2002). These figures suggest that the service user is being set up to fail or more directly not being correctly diagnosed and treated properly.

Service user’s experiences and attitudes to the services they receive can vary but most feel like the following quotation “Got no help at all. All they wanted to do is pick on me like I was a naughty little girl, and it made me very angry, and I couldn’t open all for how they treated me. I just dreaded going to see them (Harris, 200). Not only do these kinds of attitudes make users experiences of services unpleasant, but they can also increase service user’s echoes of distress. Not only are service users critical of emergency department staff, but patients admitted to hospital following self poisoning also feel isolated, ignored and inhibited by staff (Dunleavey 1992) a fast tracking of service users through the system should be considered to minimize harm resulting from their injury and to minimize distress. Service users also point out the importance of being listened to by staff even when the interaction is brief or only a single occasion (Arnold 1995). A safe environment and being listened to it especially important since service users may reveal information about their injuries that makes them feel vulnerable, fearing negative repercussions. As a result of poor stuff attitudes towards people who self harm, service users feel that they are frequently treated differently compared with service users who have not self harmed.

“I was told off by nurses and the doctors; I just felt small. They do treat self harmers different to accident people. We are classed as suicides. The hospital staff just look at you as though you’re wasting time. That’s how I felt. (Harris. 2000).

Some self harmers, however, use the practice of self harm in a ritualistic way. This type of self harm has been practiced by different cultures for centuries, for example the Maya priesthood performed auto- sacrifice by cutting and piercing their bodies in order to draw blood (Gualberto, A. 1991). It is also practiced by the sadhu Hindu ascetic, in Catholic mortification of the flesh, in ancient Canaanite mourning rituals as described in the Ras Shamra tablets and in the Shi’ite annual ritual of self-flagellation, using chains and swords, that takes place during Ashura where there Shi’ites sect mourne the martyrdom of Imam Hussein (Reference).

Another little known fact is that the animal world is prone to self harming and there is some correlation between animals and human beings on this issue. Self -mutilation in non-human mammals is well-established, although not a widely known phenomenon and its study under zoo or a laboratory conditions could lead to a better understanding of self harm in human patients (Jones, I.H., Barraclough, B.M. 2007). Zoo or laboratory rearing and isolation are important factors leading to increased susceptibility to self harm in higher mammals. Lower mammals are also known to mutilate themselves under laboratory conditions after administration of drugs (Jones, I.H., Barraclough, B.M 2007). In dogs, canine obsessive compulsory disorder can lead to self inflicted injuries, for example canine lick. Captive birds are sometimes known to engage in feather plucking causing damage to feathers or even the mutilation of skin or muscle tissue (20..?..) A good example of feather plucking in birds would be battery hens that are kept in cages with no access to movement or sunlight. Useful analogies!

Many people who engage in self harm do so not that they intend to take their life or that they are seeking attention. People who self harm do so because they are looking for some form of relief from their situation. As a coping mechanism, self harm works for the person doing it. (Reference needed on coping mechanisms) Many self harmers who seek help in the form of medical attention face an uphill struggle in the face of adversity, negativity and disbelief from the service that is in situ to help them. Negative attitudes from medical staff and social care workers affect the self harmer and they feel increasingly isolated. Within the medical profession comes a coldness not afforded to accident and ill people, along with a lack of understanding and a lack of training. Communication with the service user as well as empowerment would enable service users to have a greater say in their treatment and rehabilitation and this would go a long way in addressing this problem. Service users know why they self harm but feel they are not being listened to. Until this issue is addressed the problem will go largely unchanged. (Need references for stigma and self harm treatment in A & E)

A referral has been made by the PSNI because they are concerned about two children aged 18 months and 4 years old following their attendance at an incident of domestic violence the previous Saturday evening. Area Child Protection Committee (ACPC,2005, 9.25) state “Child protection is everyone’s business” . Gateway teams have been established within the five Health and Social Care Trusts in Northern Ireland, to deal with all referrals both from professionals and members of the public who are concerned about a child’s well being.

Social work is a profession that embraces the principles of The Human Rights Act 1998(HRA). The Children Order (Northern Ireland) 1995 (Order 1995) underpins all aspects of the powers and duties of the social work mandate governed by social work law. The Northern Ireland Social Care Council (NISCC) code of practice reflect profession ethical and values which are intertwined with law, societal values and are at the heart of how workers conduct their practice.

Article 66 of the Children Order places a duty on workers to investigate all allegations or suspicions of abuse likely to cause harm to a child. The Family Homes and DV (Northern Ireland) Order 1998 has been incorporated into the Children Order. Article 12 A, identifies the ‘risk of harm to a child from witnessing DV,’ (Order, 1995). The social work role is to assess and intervene if a child is in need or at risk of significant harm.

“Article 17 of the Order defines a child in need as unlikely to achieve or maintain a reasonable standard of health or development without the provision of services by the Health and Social Services Trust or if the child is disabled” (Order, 1995).

Upon recite of this referral the worker must take time to “tune in” to the potential risks and appropriate action as a result of this information. The worker needs to contact the PSNI and clarify the details of the referral including the severity of the DV. Multi-agency working is a key function of social work in the area of child protection and fundamental to assessment of risk. Joint working protocols exist between the PSNI and workers in Northern Ireland. The lone working policies acknowledge, violence against workers is not unheard of and the PSNI will accompany the worker to enable them to carry out the initial assessment if needed. NI is a country emerging from conflict; however, stereotypical attitudes and beliefs about the PSNI and some members of the community are deep rooted. The worker needs to assess how s/he can proceed safely.

According to the Order 1995, the welfare of the child is paramount. Social workers try to build positive relationships with parents and families. The Article 8 European Convention of Human Rights offers, “aˆ¦ protection for a person’s private and family life, home and correspondence from arbitrary interference by the State,” (www.yourrights.org).

An over authoritarian approach may serve to alienate parents but this does not mean the worker takes “unnecessary risks regarding her own or others safety”, (NISCC, 2004, 4.3).

The social worker is obliged to screen details of the people involved against the e-information system and the child protection register (CPR), for current or previous social service involvement. Names of the children need to be entered individually; it is not uncommon for one child in a family to be registered and another not. If the family or children have had previous involvement with social services and the case is now closed the manual records need to be accessed and read. If the worker has any ambiguity about the interpretation of the information, clarity must be sought with the principal social worker or whoever is the relevant party.

“Workers are accountable for the quality of their work.” (NISCC, 2004,6.0) At present the worker has no way of identifying the level of risk posed to these two children. DV is a contributory factor in half of all the serious case reviews and 75% of the cases on the child protection register. (Hester, et al.1998).

When all background information is gathered the worker needs to communicate her findings both in writing and verbally to the supervisor/team leader/manager, whom in turn has ultimate responsibility for prioritising the referral based on the available information.

Failure to follow the risk assessment policies and procedures and effectively use information can have fatal consequences for the service user. If this referral was to result in a child/ren getting harmed the social work could be held personally culpable. “Ignorance is not an excuse”, (Stafford and Hardy 1996 cited Calder, 2003, p.8).

Brearley, 1982, suggests risk is calculated by the likelihood of the variation of possible outcomes

“Past knowledge provides a reasonable basis for prediction of harm.” Stafford and Hardy (1996 cited Calder, 2002, p.8.)

The Children Order, Cooperating to Safeguard Children, 2003 and Our Children and Young People Our Shared Responsibility, 2006-2016 expresses the need for workers and all professionals to communicate. Partnership recognises the expertise of other professional’s and agencies, including the parents when it comes to the protection of children. (NISCC, 2004,6.7)

The ACPC policy states a

“child must be seen and spoken to by the worker within 24 hours and that an initial assessment of need is completed within 7 working days of receiving the referral ” (ACPC,2005,para 9.25).

The worker will undertake the initial assessment with the family. Milner and O’ Byrne (2002) describe social work as a goal directed activity. The worker needs to know the possible impact of DV on the health and development of children this age and be able to recognise the signs and symptoms of abuse.

The NISCC code of practice states a “worker needs to adequately prepare and plan all aspects of work”, (NISCC, 2004 6.4).

According to Parker and Bradley, (2003) assessment is a balance between art and science. There are no scientific tools, which can predict human behaviour or eliminate risks totally. Social work training and education equip social workers with the knowledge and skills to practice. (NISCC, 2004)

The social work profession is grounded in the humanistic principles before any direct interaction takes place the worker needs to reflect on what the serious nature of what she is intending to do.

In the area of child protection there is a considerable power imbalance between the worker and service user. The worker is effectively calling the competency of the parents into question. Workers could expect parents to be less than welcoming. It is hardly surprising given the invasiveness and instructiveness of the investigative role of child protection.

“People may feel intimidated and fearful that their children might be taken into care. This can result in hostility, anger and resentment towards the worker.” (Adams, et al, 2009 p224).

According to Farmer and Owen, (1995) Mullender, (1996) and (Mc Williams and Mc Kiernan (1995), DV is always about power and control. Their research is overwhelmingly based on male to female abuse but they do acknowledge the existence of violence against men and reciprocal violence. The worker needs to be consciously aware of this and respect the marginalized and vulnerable position of victim and abuser of DV. The worker needs to modify her own practice to address these issues sensitively and in a manner that will not further the oppression of the victim.

Various trains of thought exist as to whether empathy is a character trait or a learned skill that develops through continuous practice but it is crucial that the worker understand the importance of the perspective of the service user. Schulman 1984(cited in Cournoyer. p.22) states,

“Preparatory empathy involves “putting yourself in the clients shoes and trying to view the world through their eyes”.

Beckett and Maynard (2005) believe in the name of respect, parents have a right to know why their family is being investigated and why the worker wants to see and speak to their children. Informing the parents of their rights, including their right to complain, taking time to explain the investigation process and taking time to actively listen to parents and encouraging them to express their views will at least go in some way to upholding public trust and confidence in the social work profession. The involvement of the gateway worker will be time limited. If this family need further intervention the gateway worker needs to set the precedence for further social work involvement. If a family have a negative experience of one social worker they are likely to perceive all social workers to behave the same. Cleaver, et al (1995) stresses the need for the worker to be open and honest from the start of the process, if any trust is to be established.

Much of the assessment relies on participation of the parent, without which the worker will have great difficulty making an accurate assessment and as a result the children or the family may not get the support they need and the appropriate intervention to either meet their needs or keep them safe. (Parker and Bradley, 2003)

In the spirit of social justice and ethical practice holding the balance between the safety of the children, the importance of family life to a child and the need to avoid unnecessary interference underpins every part of the Children’s Order as it applies in practice (Children Order, 1995).

Professional ethics requires the worker to critical reflect at every stage of the process in order to think logically and make sense of what is happening.

Awareness of their own prejudices and discriminatory attitudes and a willingness to challenge them means the worker can begin to approach this family in a genuine and anti oppressive manner. According to Preston-Shoot and Agass (1990, p38)

“reactions can be determined by the workers own personal history and current emotional experiences”.

A worker who has grown up in a home where DV has been an issue may have very different feelings compared to a social worker who has never had personal experience of DV.

Workers have a professional duty under the NISCC codes of practices and in the interests of social justice not to just maintain but promote the dignity and worth of all services users. Banks (2006, p3) states, “Professional values need to distinguish between personal values.” If the worker has concerns she can explore them through supervision either with her team or senior.

Pauline Hardiker has developed the single assessment framework tool for assessing the needs of children-Understanding Needs of Children in Northern Ireland (UNOCINI) tool. The UNOCINI adopts an holistic view to assessing the needs of children. It has three interlinked areas of assessment. The needs of the child, the capacity of their parents to meet their needs and the wider family and environmental factors, such as employment and housing issues are assessed as having an impact the child’s life and well being. Our Young People Our Shared Responsibility, 2006-2016 is the Governments Ten Year Strategy’s pledge, which reflects the prevention through early intervention social policy ethos and parental responsibility and partnership principles of the Children Order are fundamental to the UNOCINI. Social workers have an ethical commitment, to promote social justice and equality to support parents in need, to bring up their children.

The aim is early identification of need, purposeful intervention, with the objective of preventing difficulties escalating and promoting the strengths and resilience of the family. Threshold of needs correspond with risk. The thinking behind this is to promote a shared understanding between professionals to identify concerns, risk, needs and strengths, particularly in the area of communication. DV is cited in threshold three of needs, (DHSSPSNI, 2007).

Mullender et al, (2004) believes children face three risks: the risk of observing traumatic events, the risk of being abused themselves, and the risk of being neglected.

Jean Paiget (1896-1980) is instrumental in constructing the idea that healthy children develop through a serious of ordered sequences, known as milestones. No two children will follow exactly the same pattern but it would be reasonable to expect that a child of 18 months would be starting to talk, walk and explore their environment. A 4-year-old would be able to walk, talk in sentences, and be out of nappies. Osofsky, (2004,p4) stresses, “Trauma due to domestic violence interferes with a child’s development.” Mullender et al (2004) whilst agreeing with Osofsky suggests that protective factors, such as a supportive not violent adult, a placid temperament and the child’s young age and lack of ability to full appreciate what is happening might help reduce the risks to children. She does point out that each child is different and will respond differently. Professional ethics and values of the social work profession emphases the need to “treat each child as an individual” (NISCC, 2004, 1.1).

“The key factors in the parenting and child domain are basic care, ensuring safety, emotional warmth, stimulation, guidance and boundaries and stability.” (Howarth, 2004,p24)

A report by Davenport in 1984 cited in Howarth (2004) discovered DV has a very negative impact on the mental health of the victim. Parents are more likely to respond with irritability and anger or fail to respond at all, rendering them emotionally unavailable to their children.

Attachment theory believes that if a child’s primary attachment is damaged in the first or second year of their life they are at significantly increased risk of developing problems later in life.

Fahlberg (1991, p.64) states

“The primary task to be accomplished during the first year of life is for the baby to develop trust in others and aˆ¦ explore their environmentaˆ¦ children growing up in a violent household may be too frightened to show inquisitiveness.”

Humphrey’s et al (2006) explored the emotional turmoil of children drawn into participating in the violence leaving the child confused and afraid and the parent undermined as a valued human being in their own eyes and the in the eyes of the child.

Humphrey’s has also drawn attention presumed attitudes that expect all mothers to love their children and treat them the same. The child that looks like the abuser or the child that is born as a result of rape may be more vulnerable to harm than the child who is none of these things.

Maslows higher hierarchy of needs believes that a child needs to feel safe and have a sense of belongingness within their family if they are to achieve their full potential, (Hoghughi and Long, 2004). Without this they are unlikely to achieve their full potential.

Smale and Tuson, (1993 cited Coulshed and Orme 1998) recommend the exchange model where all people are seen as experts on their own problems and the emphasis is on the exchange of information rather than the worker being the expert.

Listening is a core skill of any communication process. Social workers have been ridiculed in the past for their ‘know it all’ approach, often leaving families stigmatised and traumatised because of their investigations but without any purposeful intervention.

Lord Lamming (Laming report, 2003 cited in Wilson and James, 2008, p.254) following the death of Victoria Climbe, is clear that the

“aim of communication with children or about children is to gain a comprehensive understanding of a day in the life of a child”.

Children may engage through play. The worker could ask the child what TV programmes they watch or who makes dinner or puts them to bed. DV is not just about controlling people it involves controlling the household movements. The social worker needs to maintain vigilance for any visible signs of injury and needs to ask the child what happened.

Workers should engage parents at every stage of the process. The worker needs to ask the parents permission to share and collate the information; however, regardless if they agree or not the information will need to be shared in the interest of child protection.

All social work involvement needs to be proportionate to the age and developmental needs of the children and the nature and severity of the risks, concerns and strengths of the individual child and their respective family.

Farmer and Owen, (1995, p79) has highlighted that

“in the face of allegations couples often from a defensive alliance against outside agencies”.

They may have conflicting and confusing feelings of love and hate towards each other. Thompson,(2006) advised couples often have “multiple truths” of events and experiences. This advises the worker not to be drawn into giving personal judgements or opinions.

Thompson,(2006) focuses on the personal, cultural and structural model of oppression, (PCS) which might explain why women do not leave. Dobash and Dobash, (1979 cited in Cleaver, 1999) suggest that on a personal level women feel shame and guilt; they know their children are affected and they don’t report DV or seek support because they fear they will not be believed or that they may be killed for reporting it. The impact of violence can lead to the woman feeling worthless and isolated.

Culturally women are brought up from childhood to be caretakers, to comfort others and as a result of this they may believe that they are responsible for the abusers attacks, if they were a better wife, mother, cook, and then the violence would stop. The patriarchal nature of society often sees many women dependant for finance on a man. Thompson (2006) remarks, bring a child up in poverty is not impossible but it is hard.

Structurally, the lack of affordable housing and a lack of confidence in the legal system are barriers that prevent women from leaving an abusive partner. Family Homes and DV (Northern Ireland) Order 1998,Article 29 gives courts the power to remove an suspected abuser from the family home instead of removing the children. (Children Order, 1995) but this does not guarantee safety.

The new Government have warned of social welfare cut backs; the worker has to balance the needs of the family against available scarce recourses. Banks (2003 p101) states,

“a worker needs to be able to challenge agency policies and practicesaˆ¦Professional code of ethics along with education will have a role to play in this.”

A worker needs time to complete an accurate assessment. Heavy caseloads and a lack of resources have contributed to failure to protect in the past.

Empowerment is about actively finding ways that the victim can make use of intervention to help themselves move towards the survivor role and care and their children without the support of the state.

Conclusion

Accurate, precise recording are vitally important to child protection and helps build the picture of children’s lives. The risks and strengths posed to them will provide the basis for shared understanding, analysis, decision-making and plans about the children and their family.

The social worker on the Gateway team is responsible for drawing all the strands of information together. Health visitors, GP, PSNI, extended family all hold key pieces of information that could protect these children. The Gateway team is responsible for convening the initial case conference. All stakeholders need to contribute.

Similar treads of poor communication, lack of interagency working and inaccurate recording, has consistently reappeared throughout Serious Case Reviews. In 1973 Maria Colwell aged 7 was beaten to death by her stepfather. In 2007 Arthur Mc Enhill set fire to his home killing his whole family, 7 in total and the same year 17month old Peter Connolly died after suffering horrific abuse. Domestic violence was a key feature in all of these tragedies.

Pemberton, (2010, p17) advises,

“Patterns in social history and behaviour can be detected and something, which may appear insignificant in isolation, can be identified as a key warning sign in context”

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Compare, contrast and critically evaluate Crisis Intervention and Task-Centred Practice. Debate what you see as their effectiveness by outlining potential advantages and disadvantages and with reference to research regarding their effectiveness.

The British Association of Social Workers (BASW) Code of Ethics (2002:1) states that;

“The social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. Utilising theories of human behaviour and social systems, social work intervenes at the points where people interact with their environment.”

In order to promote such social change and provide high quality professional practice, social workers utilise various theoretical frameworks and apply them appropriately in order to help service users in the best way they can. The intention of this essay is to discus the key features of the task-centred practice and crisis intervention approaches, both of which are widely used methods of social work practice. With reference to research, the effectiveness and limitations of these approaches will be analyzed by outlining potential advantages and disadvantages, and by demonstrating that although these approaches have different origins, they do have some common features.

McColgan (2009:60) states that task-centred practice is;

“…a popular method of intervention in social work practice. It does not depend on any complex theory, is down to earth, makes sense and is easy to understand in its application.”

Coulshed & Orme (2006:156) believe that the task-centred approach, also known as “brief therapy, short term or contract work” is probably one of the most researched and commonly used approaches to problem solving in social work practice.

Task-centred practice was developed out of research into effective social work practice by Reid and Shyne in 1969, who found that planned, short term intervention, was equally as or more effective than long term treatment. Task-centred practice originates within social work itself, rather than being “borrowed” from disciplines outside of social work, such as psychology and sociology. Indeed, Reid (1992) states that;

“…task-centred casework rejects any specific psychological or sociological base for its methods and seeks to be eclectic and integrative” (cited in Payne, 1997:97).

At the time task-centred practice challenged the long-term psychodynamic theory behind social work which, according to Woods and Hollis (1990, cited in Cree and Myers 2008:90) expected problems to be “…deep rooted and to require intensive and long-term specialist input to address these difficulties”, however Reid and Shyne disputed this approach in favour of “…proposed time-limited, structured and focused interventions to solve problems”, which was a direct challenge to the models that encouraged those with problems to move at their own pace.

Reid and Epstein (1972) suggest that the task-centred approach is beneficial for a variety of problems, including interpersonal, social relationship, organisational, role performance, decision making, resource based, emotional and psychological. Doel and Marsh (1992) and Reid and Epstein (1972) suggest that in order to apply effective task-centred practice to such problems, a framework should be adopted, which should firstly look at problem exploration. Doel (2002) states that the first phase should consist of problem scanning and identification in order to establish the services users perspective of the seriousness of the issues. The user should then be guided to prioritise the target problems and clarify their significance and define their desired outcomes or goals. Marsh and Doel (2005:72) suggest that the use of “I want” or “we will” is a guarantee of a statement which results in a goal being achieved, rather than using verbs such as “need”. Epstein and Brown (2002:155) recommend that a maximum of three problems should be worked with at any one time – as Doel and Marsh (1992:31) point out “…too many selected problems will probably lead to confusion and dissipated effort”. The selection of targeted problems should be governed by feasibility of achievement and in accordance with the partnership of the worker (Cree and Myers 2008:93). Doel and Marsh (1992) identify that making an agreement and agreeing a goal should be a written statement of what the user wants, based on how to directly alleviate the problem. The benefits of a written agreement could include that it is in the service users own words and can be referred to at a later date. However, Epstein and Brown (2002) argue that whilst this may be more necessary with mandated service users, a verbal agreement may be sufficient. It is important to remember that the communication skills of users must be taken into account, and that appropriate media must be used in accordance with the users abilities and skills. Additionally, a verbal agreement may be less frightening for the service user, or they may not be literate, so possibly a tape recording could be used. Healy (2005:121) suggests that the agreement should document the practicalities of the intervention, such as the “duration, frequency and location of meetings” in order for both the service user and the worker to be held accountable. Cree and Myers (2008:94) state that once the practicalities of the agreement have been established, identification of how to address the problems can begin via agreeing to a series of tasks that will contribute towards achieving the goals set out, that is, alleviation of the problem. Dole and Marsh (2005:36) outline that goals ideally should follow the SMART principle; specific, measurable, achievable, realistic and timely. Additionally, goals and tasks should be detailed and clarify who will do what, when, where and how and the service user should have a major influence in deciding on and carrying out the goals and tasks (Cree and Myers 2008:94).

“In short, the goal should be the client’s goal, agreed after detailed discussion with the worker about why it is desirable, how it can be achieved and how it is evident that it has been reached. The goal should be as clear as possible, within the capacity of the client to achieve and ethically acceptable to the practitioner.” (Doel and Marsh, 1992:51)

Task implementation addresses the methods for achieving the task(s), which should be negotiated with the service user, and according to Ford and Postle, (2000:55) should be;

…designed to enhance the problem solving skills of participants…it is important that tasks undertaken by clients involve elements of decision making and self-direction…if the work goes well then they will progressively exercise more control over the implementation of tasks, ultimately enhancing their ability to resolve problems independently”.

According to Doel (2002:195) tasks should be “carefully negotiated steps from the present problem to the future goal.”

Once tasks are set, it is important to review the problems as the intervention progresses in order to reassess that the tasks are still relevant to achieving the goals. Cree and Myers (2008:95) suggest that as circumstances can change, situations may be superseded by new problems. The workers role should be primarily to support the user in order to achieve their tasks and goals which may include providing information and resources, education and role-playing in order to handle difficult situations (ibid:95).

The exit stage of the intervention should have been anticipated at the initial phase, in that the contract or agreement will have been explicit about the length of the intervention, and both the service user and worker will be aware of the timescale in which to complete their tasks. A time limit is important as it guards against drift, allows time for a review and encourages accountability. It also acts as an indicator of progress (Adams, Dominelli and Payne, 2002).

According to Cree and Myers (2008:96);

“…the last session needs to review what has been achieved; how the tasks have been completed; to what extent the goals have been met; and what the service user has learned from the process that can be usefully taken into their future lives.”

Wilson et al (2008) suggest that the final phase should involve the service user and the worker revisiting the initial problems and comparing them to how the situation is now, along with what the underlying achievements were, and what has been learnt in the process. Additionally, the service user is encouraged to explore how to use the skills learnt for the future, and how the intervention will now end, for example, possible new contracts for further work or referral to another agency.

In contrast, the conceptual origins of crisis intervention come from varied sources, primarily from mental health and have a long history of development (Roberts 2005 cited in Parker 2007:116)

Caplan (1961) and Roberts (1990) (cited in Parker 2007:115) state that crisis is;

“…a time limited period of psychological distress resulting from exposure to or interpretation of particular situations or longer term stress that individuals cannot deal with using tried and tested or novel means of coping.”

The theoretical basis of crisis intervention has developed in sophistication, namely through the work of Gerald Caplan, an American clinician, following Dr Erich Lindemann’s study of grief reactions after a night-club fire in Coconut Grove, Boston, USA in 1943 in which almost 500 people died. Lindemann interviewed some survivors and the relatives of those who died and concluded that when faced with sudden crisis, the human capacity to deal with problems faltered. An individuals usual coping mechanisms are no longer adequate to take on board the experiences involved following a crisis and these experiences consequently challenge ones normal equilibrium, or homeostasis. Furthermore, during the Korean war in the early 1950’s, it was discovered that psychiatric first-aid given immediately to front-line soldiers, often quickly restored them back to duty, whereas those who were sent home for protracted institutional treatment responded slower to intensive therapy, which could suggest that institutionalization confirmed there was a serious underlying problem (Fell 2009).

The experience and resolution of crises could be said to be a normal process which is inevitable at some point during a person’s life, however, defining exactly which events or situations constitute crises is more troublesome, as they are construed as crises due to individual perception or reaction to an event, not the actual event itself (O’Hagan 1986, cited in Parker 2007:117). The concept of “crisis theory” provides workers with a theoretical framework of the adaptation processes of the individual following such events that are seemingly overtly stressful and unmanageable. Crisis intervention takes the concept of this theory and applies it to the understanding of the individual’s experience, and suggests certain steps to take in order to help those who are experiencing crisis (Wilson et al 2008:361).

Coulshed (1991:68) believes that one of the most significant features of crisis intervention is that crisis does not always indicate an emergency or dramatic event. The crisis instead, may be “developmental” and the result of a new experience such as starting school, adolescence, leaving home, going to university, getting married, or the anticipated death of a relative or friend, or indeed oneself. Similarly, an “existential” crisis refers to inner anxieties in relation to ones purpose, responsibility and autonomy, for example, a middle life crisis. In both cases adjustment fails because “…the situation is new to us, or it has not been anticipated, or a series of events has become too overwhelming” (ibid). For many people, these challenges will not constitute a crisis, although they may feel stressful, but it could be recommended that, in practice, the worker remembers the subjective nature of crisis, in order not to dismiss a service users experience, which would suggest that there are standard reactions to events, as Hoff (1990) states; “…what is a crisis for me may not be a crisis for you”.

Alternatively, a “situational” crisis could be said to be an event that happens which is out of ones control, or out of the realms of normal, everyday experience, for example natural disasters, sudden illness or death, sexual assault, abortion, domestic violence, redundancy or relationship breakups (Aguilera 1990). Murgatroyd and Woolfe (1985) however, believe that the threshold level of how an individual deals with such events is not the same for everyone, which leads one to assume that it is how someone comes to terms with the event rather than the event itself, in agreement with O’Hagans earlier statement. Likewise, an individual may be a particularly resilient person, or has previous experience of such situations, or they may have a strong support network of family and friends. Indeed, given an example such as a terminal illness, preparation work may be underway before the inevitable occurs and therefore not develop into a crisis situation (Wilson et al 2008).

Caplan (1964) suggests that crises are time-limited, usually lasting no longer than six weeks, and that an individual’s capacity to cope with problems and return to a steady state is based upon a persons internal psychological strengths and weaknesses, the nature of the problem and the help being given. Caplan (1964) also describes the stages of crisis whereby an emotionally hazardous situation presents uncomfortable feelings and signals change in homeostasis, in turn motivating actions to return to normal through employing usual coping mechanisms, which in most cases, are successful in a short period of time. Alternatively, in the case of an emotional crisis, the usual coping strategies are ineffective and the discomfort and unpleasant feelings intensify, cognitive disorganisation increases and novel coping methods and problem-solving techniques are employed to reduce the crisis. The individual then seeks help and support from others and employs an adaptive crisis resolution which deals successfully with affective and cognitive issues and new problem-solving and coping behaviours are developed. Conflicts raised by the crisis are identified and work to resolve them is begun, upset is subsequently reduced and there is a return to the pre-crisis level of functionality. However, maladaptive crisis resolution sees the individual implement novel problem-solving and coping and adequate help is not sought. Underlying issues remain unresolved and sources of help are not fully utilised. Although the disquiet is reduced the individual functions at a less adaptive level than before the crisis. In an adaptive post-crisis resolution, the individual becomes less vulnerable in similar situations due to past resolved conflict, inferring that the novel and adaptive coping skills and problem solving behaviours have been learned and applied. Therefore, individual functioning may have improved, personal growth taken place, and the likelihood of future emotionally hazardous situations of a similar nature developing into a crisis is reduced. Finally, Caplan (1969) describes the maladaptive post-crisis resolution whereby the individual is more vulnerable than before because of a failure to deal effectively with underlying conflicts. The individual has learned maladaptive strategies to cope with emotionally hazardous situations, such as drinking or problem avoidance, and in general their functioning may be less adaptive than in the pre-crisis state, potentially resulting in further emotionally hazardous situations developing into a crisis.

In order to implement effective practice for successful crisis intervention Roberts (2000) recommends practitioners should follow a seven stage model beginning with risk assessment, in order to establish if the person needs immediate medical attention, are they considering suicide as a “solution”, are they likely to injure themselves, if they are a victim of violence, is the perpetrator still present or likely to return, if there are children involved are they at risk, does the victim need transport to a place of safety, has the individual sought emergency treatment of this sort before and if so what was the outcome? It is essential to establish rapport with service users who are experiencing an episode of acute crisis, to include offering of information regarding help and support, and genuine respectfulness and acceptance of the person in line with the anti-oppressive and anti-discriminatory practice, therefore adhering to the GSCC Code of Practice. The worker then needs to establish the nature of the problems that have led to the crisis reaction and encourage an exploration of feelings. Roberts (2000) believes this is a key element of the model, whereby service users should be encouraged to express their feelings in a safe and understanding environment within the context of an empathic therapeutic relationship with the worker. The worker should consider alternative responses to the crisis through active listening and encourage the service user to think about what alternative options there are available and what they feel they can bring to this new situation that they find themselves in. Roberts (2000) concludes that an action plan should be developed and implemented which involves the identification of a particular course of action in order to move beyond the crisis state successfully. The service user needs to establish a full understanding as to what happened, why and what the result was, to understand the cognitive and emotional significance of the event, and to develop a future plan based on real situations and beliefs rather than irrationality. Finally, a follow-up plan and agreement can be drawn up between both service user and worker if any further help is needed and by whom.

It is evident that there are various advantages and limitations as well as some common features between both of these methods of practice. In fact Reid (1992) believes that crisis intervention has been influential to the development of task-centred practice. A major advantage for task-centred practice is that it offers an optimistic approach that moves focus away from the person as the problem, to practical and positive ways of dealing with problems. Coulshed & Orme (1998) suggest that task-centred practice does not assume that the problem resides only in the service user and therefore attention is paid to external factors such as housing and welfare and the strengths of individuals and their networks. However, Gambrill (1994 cited in Payne 1997) argues that neither model deals with social change and may not take account of structural oppression such as poverty, poor health, unemployment or racial or gender discrimination or where the problem may not be easy to overcome without political or social change;

“…the failure of political will to respond realistically to deep-seated problems of poverty and social inequality and its effectiveness in dealing with presenting problems may result in society avoiding longer-term and more deeply seated responses to social oppressions” (Payne, 1997:113).

In addition, Wilson et al (2008) argue that the crisis intervention model does not take into account cultural differences regarding traditions when coping with acute distress and the loss of a loved one for example. The criticism is that crisis intervention theory is based on a very western philosophy, which “patches up as quickly as possible”. It could be suggested therefore, that if workers carry out a thorough and sensitive assessment before intervention, this should be avoided. On the other hand, Coulshed & Orme (1998:55) believes that the task-centred approach is more generic, in that it is considered to be ethnic sensitive and can be applied to many situations with different user groups;

“…the task-centred approach is the one most favoured by those who are trying to devise models for ethnic-centred practice because its method is applicable to people from diverse cultural backgrounds”.

Therefore in keeping with anti-discriminatory practice which is integral to social work ethic and the GSCC Code of Practice.

It could be argued that the success of these two approaches within social work comes from the fact they are brief and time efficient and therefore economical interventions, both for service user and from the care-management perspective. In addition, both approaches involve the service user in examining and defining their own problems and finding ways in which they can work on them using their own resources and strengths. This enables them to regain control of their lives and promote empowerment either by success in problem solving in order to build confidence as in the task centred approach, or helping people become emotionally stronger through learned experience, as with crisis intervention, rather than understanding the origins of present problems in past experience. This in turn helps the service users ability to cope in the near and distant future and become more capable of solving subsequent problems without help (Payne 1997). Equally, the fact that short-term interventions should curtail the service users dependency on the worker, further enhances empowerment. As Ford and Postle (2000:53) state;

“The dangers of social work effectiveness becoming dependent on the worker/ client relationship, which may or not work out, are minimised in the short-term.”

The tasks and goals established in task-centred practice are chosen because they are achievable, that is the mutual and specific agreement or contract set up between the service user and the worker ensures that the success of the intervention relies upon the acceptability and participation of the tasks (Wilson et al 2008). As a result of the mutuality of the partnership, anti-oppressive and anti-discriminatory practice and empowerment are at the core of the task-centred approach, all which are key to the GSCC Code of Practice. However, Rojek and Collins (1987:211) point out that as that as task-centred practice is based on contractual intervention, this could set up an unequal power relationship between the worker and the service-user;

“As long as social workers have access to the economic and legal powers of the state and clients contact social work agencies as isolated individuals with ‘problems’, then there is the basis for inequality. Contract work does not get round these points by affecting an open and flexible attitude.”

Similarly regarding power base, Trevithick (2005) believes that the crisis intervention approach can be a highly intrusive method which is too direct and can raise a number of ethical issues such as making decisions on behalf of the service user if they are too distressed to do so themselves, which in turn may offer potential for oppressive practice on behalf of the worker. However Kessler (1966) believes that during the disequilibrium of crisis, a person has more susceptibility to influence by others than during periods of stable functioning which provides a unique opportunity to effect constructive change. This point could be argued in that the “susceptibility to influence others” that Kessler describes is in itself oppressive, although Golan (1978); Baldwin (1979); Aguilera and Messick (1990); Olsen (1984) (cited in Parker 2007:116) maintain that this time of disquiet motivates willingness to change, and this is when the practical application of crisis theory is effective. However, it could be suggested that that this is similar to the bargaining stage that Kubler-Ross (1970) describes in the five stages of grief, whereby an individual becomes so desperate to resolve a situation, that they are willing to try anything, even if it means “striking a deal with God”. Accordingly, Coulshed and Orme (2006 cited in Parker 2007:117) see its value in working with people at points of loss and bereavement, which they believe has resonance with the use of this intervention. This poses the question as to whether crisis intervention is more of a “situation specific” intervention. However, Poindexter (1997) believes that crisis intervention is suited to individuals who have experienced a hazardous event, have a high level of anxiety or emotional pain, and display evidence of a recent acute breakdown in problem-solving abilities, therefore implying that this approach could be applied to a range of situations or problematic events.

Both interventions can be seen as time-limited approaches that “superficially fit well with care-management” (Ford and Postle, 2000:59) which implies that they are only used because they fit into the routine and schedule driven aspects of care management rather than for their effectiveness. It could therefore be suggested that due to the general pressures of time, the worker may try to fit either intervention around their workload, rather than around the service user’s needs, which in turn may restrict the development of empowerment within the service user, and ultimately not address any underlying problems. Although this is a rather bureaucratic outlook, it could be said to be a sign of the times that most things are increasingly driven by targets and financial considerations. Whilst both approaches seem to satisfy agency requirements as well as maintaining professional practice, Reid and Epstein (1972) believe that the task-centred approach is more structured compared to crisis intervention (cited in Payne 1997:97). It could be suggested in which case, that task-centred practice is more beneficial for the less experienced worker as it follows more defined framework. In addition, it could be fair to say that this method of intervention could be useful for reflective practice due to it following such a framework; the worker, as well as the service user, has to be committed to a series of planned work, therefore could be a valuable tool for future guidance in a professional capacity.

Further to the constraints of short term interventions Reid and Epstein (1972) suggest that these approaches may not allow sufficient time to attend to all the problems that the service user may want help with and that clients whose achievement was either minimal or partial thought that further help of some kind may be of use in accomplishing their goals.

Task-centred practice is an approach which depends on a certain level of cognitive functioning. Doel and Marsh (1992) suggest that the service user must be of rational thought and be capable of cognition in order for the intervention to be effective, therefore may not be suitable for those with on-going psychological difficulties or debilitations;

“…where reasoning in seriously impaired, such as some forms of mental illness, people with considerable learning difficulties or a great degree of confusion, task-centre work is often not possible in direct work with that person.”

It is evident that both the task-centred and crisis intervention approaches are popular and generally successful models of social work practice and can both be used in a variety of situations. Both approaches are based on the establishment of a relationship between the worker and the client and can address significant social, emotional and practical difficulties (Coulshed & Orme 2006). They are both structured interventions, so action is planned and fits a predetermined pattern. They also use specific contracts between worker and service user and both aim to improve the individuals capacity to deal with their problems in a clear and more focused approach than other long term non directive methods of practice (Payne 1991). Despite their different origins and emphasis, both of these approaches have a place in social work practice through promoting empowerment of the service user and validating their worth. Although there are certain limitations to both of the approaches, they do provide important frameworks which social workers can utilise in order to implement best practice.

References

Coulshed, V. and Orme, J. (2006) Social work practice . 4th ed. Basingstoke, Palgrave. Macmillan.

Doel, M. and Marsh, P. (1992). Task-centred Social Work. Aldershot, Ashgate.

Healy, K (2005) Social work theories in context : creating frameworks for practice. Basingstoke:Palgrave

Poindexter, C. C. (1997) Work in the aftermath: Serial Crisis Intervention for People with HIV Health & Social,May, 22, (2), 1-3.

Adams, Dominelli and Payne (2002) Social Work: Themes, Issues and Critical Debate (2nd edn) Palgrave

Coulshed, V. (1991) Social Work Practice: An Introduction, Basingstoke: Macmillan/BASW

Ford and Postle (2000) Task-centred Practice and Care Management, in Stepney and Ford Social Work Models, Methods and Theories Russell House

Payne, M (1997) Modern Social Work Theory (2nd edn) Macmillan

Reid and Epstein (1972) Task-centred casework Columbia University Press

Reid, W. J. (1992) Task Strategies New York: Columbia University Press

Trevithick, P (2005) 2nd Edition, Social Work Skills: A Practice Handbook, Philadelphia: Open University Press

Caplan, G. (1964). Principles of preventative psychiatry. New York: Basic Books

Reid, W. J. (1992) Task Strategies: An Empirical Approach to Clinical Social Work, New York: Columbia University Press

Reid, W. J. and Shyne, A. (1969) Brief and Extended Casework New York: Columbia University Press

Aguilera, D. C. (1990) Crisis Intervention: Theory and Methodology 6th edition St Louis: Mosby and Co

Parker, J. (2007) ‘Crisis Intervention: A Practice Model for People who have Dementia and their Carers’, Practice 19 (2), 115-126

Marsh, P. and Doel, M. (2005) The Task Centred Book Aldershot:Ashgate

Hoff, L. A. (1990) Battered Women as Survivors , London: Routledge

Rojek, C and Collins, S. A. (1987) ‘Contract or Con trick?’ British Journal of Social Work, 17, 199-211

Epstein, L. and Brown, L. (2002) Brief Treatment and a New Look at the Task Centred Approach, Boston, MA: Allyn and Bacon

Doel, M. (2002) ‘Task-centred work’, in R. Adams, L. Dominelli and M. Payne (eds) Social Work: Themes, Issues and Critical Debates (2nd edition), Basingstoke: Palgrave

Reid, W. J. and Epstein, L. (1972) Task Centred Casework, New York: Columbia University Press

Kubler-Ross, E. (1970) On Death and Dying, London: Tavistock

Coulshed, V. and Orme, J. (1998) Social Work Practice: An Introduction, 2nd edition, Basingstoke: Macmillan/BASW

Cree, V. and Myers, S. (2008) Social Work: Making a Difference, Bristol: The Policy Press

Wilson, K, Ruch, G. Lymbery, M. Cooper, A. (2008), Social Work: An Introduction to Contemporary Practice, Essex: Pearson Education Limited

Roberts, A. (2000), Crisis Intervention Handbook: Assessment, Treatment and Research, 2nd edition, Oxford: University Press

Murgatroyd, S.J. and Woolfe, R. (1985), Helping Families in Distress: An Introduction to Family Focussed Helping, Michigan: Harper and Row

Kessler, J. W. (1966), Psychopathology of Childhood, California: Prentice-Hall

Fell, B. (2009)

McColgan (2009)

BASW (2002)

Referring to case study 2: Helen, a 78 year lady, a Section. 2 and a Section. 5 of The Community Care Delayed Discharges Act 2003 have been issued and Social Services have 72 hours before they are cross charged. This Act penalises local authorities who cannot provide for discharged hospital patients, as it ensures NHS patients receive adequate care when being discharged from hospital. It sets out timescales which Social Services have to comply with and if there is a delay in discharge whereby Social Services are to blame they will be cross charged ?100.00 per day under s.6 of the ‘Liability to make Delayed Discharge payments’. This is the main provision of this Act along with on-site multi-disciplinary working. However, if the delay in service provision is down to the NHS then reimbursement does not apply and if during this process there is a dispute then this is under s.9, ‘Dispute Resolutions’ of the CC(DD)A 2003.

The law states that if a s.2 and a s.5 of CC(DD)A 2003 have been issued together then the process is as follows:

“This section applies where a section 2 notice has been given. Subsection (2) ensures that the NHS body responsible for issuing the section 2 notice to the social services authority, and any other NHS body which may need to provide services to the patient upon discharge, must consult the social services authority before deciding which services it will make available upon discharge. This is to ensure that a complete package of care can be put in place smoothly and without duplication or omission of any particular service. The responsible NHS body will in the first instance normally be a hospital but the majority of NHS services upon discharge are likely to be provided by the patient’s Primary Care Trust. The social services authority must be consulted about all NHS services that are to be provided”

The first step in the case of Helen would be to have a statutory meeting with the social services manager to discuss Helen’s situation and to establish the legal framework and service delivery to be applied. The NHS and Community Care Act 1990 (NHSCCA) was enacted as a result of unfair treatment of older people, as it gave them the right to an assessment to services. The main principle and rational of the NHSCCA 1990 is to provide people with relevant services to enable them to live independently in their own homes, rather than moving them into a residential setting. Although this piece of legislation is considered to be complex it has a number of powers and duties imposed on local authorities.

The primary role of local authorities with community care responsibilities is to ensure that:

Adult social care is delivered effectively

Services users wishes are taken into account, and

Services are delivered safely (Brayne & Carr, 2010:508).

The main statutory duty for social workers of the NHSCCA 1990 is Section 47. Under s.47 (1) as social workers we have a duty to do a needs lead assessment and this is a must in the case of Helen. The National Service Framework for Older People provides a framework for health and care services for older people, and this is an important development whereby social work assessments are integrated with health care assessments. As the duty social worker when doing an assessment there are two aspects that should be considered. First, there is the assessment of Helen’s needs not wants; second, bearing in mind the outcome of that assessment, the decision to provide (or not) particular services. However, during the NHSCCA 1990 s.47(1) needs lead assessment, if Helen is identified as being ‘disabled’, she has additional rights as set out in s.47(2). During this assessment the local authority must, under s.47(3)of the NHSCCA 1990, inform the Health or Housing authorities if it appears Helen may require services which they could provide (Braye & Preston-Shoot, 2010).

The roots of social care and social work lie in the National Assistance Act 1948 (NAA). Section 29, Part 3 refers to specific groups such as older people and to qualify for services under this Section the law states:

“A local authority may, with the approval of the Secretary of State, and to such extent as he may direct in relation to persons ordinarily resident in the area of the local authority shall make arrangements for promoting the welfare of persons to whom this section applies, that is to say persons aged eighteen or over who are blind, deaf or dumb, or who suffer from mental disorder of any description and other persons aged eighteen or over who are substantially and permanently handicapped by illness, injury, or congenital deformity or such other disabilities as may be prescribed by the Minister (www.legislation.gov.uk/ukpga/Geo6/11-12/29/section/29).

It is clear that where there is a legal statutory duty, you have to consider the implications of accountability within the social work profession and this in turn can cause tensions between legal framework and the General Social Care Council’s codes of practice. For example, it is difficult to reconcile the values of anti-discriminatory and anti-oppressive practice with some of the terminology utilised in the National Assistance Act 1948, such as deaf or dumb. However, as Helen’s needs meet this definition, as she is considered to be a s.29 service user and any provisions for Helen will be made under The Chronically Sick and Disabled Persons Act 1970 s.2.

“This places a duty on local Authorities to assess the individual needs of everyone who falls within Section 29 of the National Assistance Act 1948” (Brammer, 2010:402).

In addition older people can be offered residential care under the National Assistance Act 1948 s.21 and home care and laundry services under the National Health Service Act 2006 Schedule 20(3). Under s.2 of the CSDPA 1970 the provision of welfare services, local authorities are required to provide services such as an occupational therapist (OP). The OP can do functional assessment to establish the provisions required and to aid in the transition from hospital to the home. The main provisions do not include personal care but assesses how the service users’ function, for example get dressed, and get out of bed in hospital or at home. The fundamental rational is to power and enable the service user to get back to their former ability.

The Health and Social Services and Social Security Adjudication Act 1982 s.17, provides local authorities the power to make reasonable charges for non-residential services. Under this legislation the first six weeks of intermediate care is free, NHS is free at delivery social services is not. Intermediate care or reablement is a term used to represent a range of integrated health and/or social care services that as part of an agreed care plan aim to:

Promote faster recovery from illness

Prevent unnecessary admission to hospital

Support timely discharge following an acute hospital admission

Prevent premature admission to long-term residential care

Maximize your chances of living independently (www.ageuk.org.uk ).

It was introduced to bridge the gap for people who were medically fit for discharge but were unable to return to independent living. Reablement typically it lasts for no more than six weeks and is provided without charge to the service user. Helen will receive the reablement service for six weeks and if further support is required, then Adult Social Care services may be chargeable.

“Research evidence confirms that reablement schemes are well placed both to meet the preferred outcomes of service users and to achieve cost effectiveness in service delivery, when compared with alternatives such as longer term care” (Braye et al., 2004: 113).

Once a community care assessment is carried out, we need to make decisions about what support will be provided for Helen. Helen would be required have a financial assessment by a Financial Assessment Benefits Advisor (FABA). The FABA will carry out an assessment on Helen’s financial situation and ensure she is claiming any state benefits she may be entitled to. They will need to see proof of her income and, savings and will ask for details about her expenses. This assessment is straightforward and the officers will try to make it as pleasant as possible.

National guidelines published by the Department of Health called ‘Fair Access to Care Services’ (FACS) provides Social Services with an eligibility framework for Adult Social Care to identify whether or not the duty to provide services under this framework. The national FACS policy states that local authorities may take account of the resources available to them in deciding which needs to meet. FACS divides need into four categories: critical, substantial, moderate or low. Thus the concept of need is determined by factors such as the availability of resources and this in turn causes tensions between policy, practice and law. Essex local authorities are just meeting critical needs at present and although having rights which are legally enforceable do not necessarily imply the need will be met due to funding within Social Services.

“to ensure that older people are treated as individuals and they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries” (Department of Health, 2001a, Standard 2).

Social Services are required by law to provide equipment for the home free of charge if the service user does not have any liquid assets. However, Helen does have an owner occupied property but does not have any savings, so therefore community care services will be provided by Social Services free of charge. Local authorities have the power, and in some cases a duty, to charge for certain community care services, under the National Assistance Act 1948 and the Health and Social Services and Social Security Adjudications Act 1983 (White et al, 2007). Community equipment includes aids such as raised seats, walking sticks; grab rails and shower mats, commodes and minor adaptations that assist daily living to promote independence in the home.

If Helen wishes to have help managing her affairs, then provided she has mental capacity she can appoint someone else to make decisions on her behalf. The Mental Capacity Act 2005 (MCA) makes it possible to produce a Lasting Power of Attorney (LPA) to continue beyond any future loss of capacity by Helen. The LPA can cover property and financial affairs, or personal welfare (including health care and treatment) or both. However, this must be registered with the Public Guardian before it can be used.

(www.direct.gov.uk/en/Governmentcitizensandrights/Mentalcapacityandthelaw/Makingarrangementsincaseyoulosementalcapacity/DG_185921)

The more capable older people are mentally the less likely it is that others will intervene in the choices which they make. However, for relatives these decisions may provoke anxiety and quilt. In such situations the capacity of the service user becomes an important factor in the decision process. Everyone has capacity unless stated otherwise and under the Human Rights Act 1998, Article 5(1) grants a general ‘Right to liberty and security of person’. This Article covers rights to liberty, which has self-evident relevance to the detention of people with mental health problems. Under Article 5(1)(e) three conditions must be met, except in the case of an emergency:

A true mental disorder must be established before a competent authority on the basis of objective medical expertise;

The mental disorder must be of a kind or degree warranting compulsory confinement;

The validity of continued confinement depends on the persistence of such a mental disorder (Johns, 2010:32).

With regards to the allegations that Helen has dementia we must have reasonable belief before making judgements on Helen’s mental capacity. However, it is necessary for Social services to investigate, for example look at her medical records to see if this has been confirmed by a medical professional, such as her General Practitioner. However, there is the issue of confidentiality to be considered and as such we would require Helen’s consent in obtaining this kind of information. The Data Protection Act 1998 is concerned with the protection of Human Rights in relation to personal data. The aim of the Act is to ensure that personal data is used fairly and lawfully and where necessary, the privacy of individuals are respected. It sates:

“An Act to make new provision for the regulation of the processing of information relating to individuals, including the obtaining, holding, use or disclosure of such information” (http://www.legislation.gov.uk/ukpga/1998/29/introduction).

It is important to note that the Human Rights Act 1998, encompasses every single act within the United Kingdom’s legal system. For health and social care it enables the legal framework to meet the requirements of service delivery. Due to allegations and concerns made by Stephanie, Helen’s daughter, it is necessary to undertake a formal documented assessment under the Mental Capacity Act 2005 (MCA) Section.1. This assessment is known as the MCA model and has to be conducted by two professionals of different agencies in order to confirm Helen’s mental capacity. The MCA 2005 codes of practice sets out five statutory principles and these are:

A person must be assumed to have capacity unless it is established that they lack capacity.

A person is not to be treated as unable to make a decision unless all practical steps to help him to do so have been taken without success.

A person is not to be treated as unable to make a decision merely because he makes an unwise choice.

An act done or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests.

Before this act is done, or the decision made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action (www3.hants.gov.uk/adult-services/health-wellbeing/adultmh/mental-capacity-act/mca-principles.htm).

Case law refers to cases which have changed legislation and the story of an autistic man detained in Bournewood hospital under the Mental Health Act 1983, changed the rights for people who lack capacity. His carers successfully challenged his unlawful detainment and deprivation of liberty, by taking the case to the European Convention of Human Rights (ECHR). In 2004 the European Court judgment of the appeal of R v. Bournewood Community and Mental Health Trust, ex parte L [1998] 3 ALL ER 458, was forced to change and the Bournewood ruling and now provides extra protection for the human rights of people who lack capacity and find themselves deprived of their liberty (Brammer, 2010).

There are two statues to consider when looking Helen’s case, the Mental Health Act 1983 (MHA) and the Mental Capacity Act 2005 (MCA) (both amended by the Mental Health Act 2007 (MHA 2007)), which provide different kinds of powers and duties for Social Services with regards to Helen’s mental capacity. Fennell (2007) indicates that both acts provide safeguarding against arbitrary deprivation of liberty which would contravene Articles 5 and 8 of the Human Rights Act 1998.

Helen may be medically fit but mentally not ready to go home and if this were to happen this can delay discharge as this would require waiting for assessments to be completed and therefore, the NHS would now be responsible for the delay. As the service user/patient’s circumstances would have changed, the NHS would have to withdraw the existing notice and re-notify social services under s.2 of the Community Care (Delayed Discharges) Act 2003. Re-notification of this kind cancels the previous notice and restarts the process, meaning that social services must reassess the patient and, after consulting the NHS body, decide when the patient will be ready to be discharged.

Social care services, which are provided by public authorities, provide support for individuals, families, carers, groups and communities. In most cases, whenever you need healthcare, medical treatment or social care, you have the right not to be discriminated against because of your age, race, gender, gender identity, disability, religion or sexual orientation. On the 1st October 2010, the Equality Act became statute. It provides anti-discriminatory law and has replaced the Disabilities Discrimination Act 1995 and the Chronically Sick and Disabled Persons Act 1970.

“provides a new cross-cutting legislative framework to protect the rights of individuals and advance equality of opportunity for all; to update, simplify and strengthen the previous legislation; and to deliver a simple, modern and accessible framework of discrimination law which protects individuals from unfair treatment and promotes a fair and more equal society” (http://www.equalities.gov.uk/equality_act_2010.aspx).

In summary when Helen is medically fit to leave hospital, social workers are responsible for ensuring the transition from hospital, back home is managed in a sensitive way. Helen is currently receiving meal on wheels and although additional support may be needed it is clear she will require continuing care. This is the name given to the care needed by an adult who requires help over an extended period of time to assist in their daily life. This package of care involves services and funding from both the NHS and Adult Social Care.

There are many aspects to consider when working within legal frameworks in Adult Social Care, such as statutory duties, service users rights and tensions which can occur when working a multi-disciplinary setting. In order to determine a sufficient and accurate care plan, the legal statutory duties and the codes of practice laid out by the General Social Care Council should guide practice but ultimately the needs of the services user should be at the fore.