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According to Maurer & Smith (2005), organizational policies and practices are influenced a lot by the national rules, legislation and service standards. There are many rules, legislations and services like care standard act, care quality commission, commission for social care inspection, race relation act, age relation act, gender discrimination act which aims to ensure the best quality care for the people with all age groups. From the scenario, we have seen that Mr. Frazer is suffering from Alzheimer disease and he needs both long term and short term care as he is passing his days with lots of difficulty.

Hamm (2007) has stated that, people with Alzheimer disease need more likely long term cares. The UK legislations have set up lots of policies and standards so that organizations can give the best the possible care to their clients. Among them, the care standard act 2000 describes that, all the care homes or residential homes must fulfill some specific requirements which are necessary to take care of their patients or clients. For example, it describes a category of people who are not suitable to work with vulnerable adults. In addition, it reforms a regulatory system for the care service organizations such as care homes, children’s homes, nursing homes, domiciliary agencies, voluntary adoption agencies, fostering agencies. While providing service to a patient like Mr. Frazer, they have to maintain the legislations. So, a service provider will must check whether they have employees with sufficient knowledge on Alzheimer disease before involving him/her to give him care. For example, whether she/he has got knowledge for the reason of this disease, medication, clinical trials, first aids, communication method, special needs etc. Thus legislation and national service standards influence organizational policies and practices for achieving best possible outcomes for people like Mr. Frazer.

Factors that may affect the achievement of best possible outcomes for Mr. Frazer

According to Gauthier (2000), there are many factors that can affect the achievement of best outcome of people with Alzheimer disease as they usually need both long term and short term care. Some of the factors are given below:

Problems in communication: Communication problem creates severe problems while providing care as sometimes they can not understand both written and spoken language because of the damage of corresponding nerve. In addition, patients may speak native language where care giver does not speak the same. In this case, misunderstanding may occur that leads to negative outcome for both groups. Sometimes they may not understand proper language, sign language, body language or meaning of normal picture. In these cases, doctors or care workers may fail to realize their needs and may not the best care.

Aggression: Aggressiveness is common often among the Alzheimer patients. So, they may feel irritated if they are asked to describe about their present health condition. In the same time, care givers or doctors will not know patient’s needs if he/she does not tell them. If they are requested to explain more than once, they become aggressive other than helping them by giving answer.

Culture, attitude and beliefs: Health care providers may fail to realize the cultural needs of patients. People from different culture have different cultural norms, beliefs, attitude and expectation. So, lack of cultural knowledge and about their belief can obstacle in the way of achieving best compliance. (Treatment and lack of adherence to medication for TB among Hispanic immigrants is one example)

Education and income: Sometimes, patient may think that, they are being asked for unnecessary information by taking the chance of their lower education and income. Also, they might need to pay them for any particular type of treatment though they are reluctant. This can create barrier to achieve the best outcome as well.

National rules and legislations: According to McHale & Gallagher (2003), a mature patient has the right to refuse treatment. Sometimes, they can say that the information which asked for will strike on their confidentiality or respect. So, information may not be available though that is essential for their safeguarding. In these cases, doctors or social workers may take decision against their wishes which will not let them to achieve best outcome.

Communication between care workers and individuals contribute to the delivery of outcomes

According to Rabins et al (2006), usually people with Alzheimer disease face difficulty while communicating with someone. They may not realize even the simple words. In some cases, their understanding can be fully reverse from the speakers and they may react violently. So, we must be very careful while presenting something to them. A few ways are given below for effective communication to achieve the best outcome.

Awareness while speaking: Cayton et al (2008) have stated that, the care givers must be aware of their body language and voice of tone while talking with them. They must communicate very politely otherwise patients may feel threatened, undermined or confused which can rise the feeling of isolation, agitation and undermine the trust.

Mentioning name: Cayton et al has noted that, care givers must introduce themselves clearly before starting conversation with a patient. If patient’s condition is critical then we may tell them our address as well to make the better feelings of the patients. Care giver or doctors should speak quickly, loudly or distinctly by no way.

Questioning: Obviously care providers or doctors need to ask questions to know patients’ condition but they must not use long sentences to ask them any question as they need longer time than others to understand the meaning even sentence is not big enough. In addition, they should not be asked more than one question at a time. Also, they should be asked question that require answer only yes or no (Sadowski & Wisniewsk, 2004). Thus any individual can ensure the best outcome for the patients like Mr. Frazer.

Question 2
2.1 Factors that may have contributed to loss of independence, non-participation and social exclusion for Ellen

According to Arber & Evandrou (1993), there are many factors which can contribute to loss of independence, non-participation and social exclusion and these can be being dependent to someone including care workers, not given time to make choice for them, constraint, changing something related to them without taking their permission, not giving chance to participate in decision-making.

Dependency: Most of the cases, vulnerable adults like Mrs. Ellen loss their independency and social exclusion because of being dependant to someone such as care workers. Sometimes the patients may not be permitted to carry their day to day activities because of lack of ability or risk. Service users’ physical and mental conditions may be considered strictly. They may not be given permission to choose how they will spend their times, how they spend their money, where will they spend their leisure time, what will be their regular diet etc. because of lack of skills. As a result, they will loss their minimum capacity to lead a life of their own. So, they may be reluctant to participate in social events as it may be insulting for them that they are dependant.

Keeping away from decision making: From the scenario, we have seen that Mrs. Ellen was given chance to make her own decision. But, usually service users in the care homes or nursing homes may not be given this opportunity because they may cause a problem. This can cause frustration and they become more dependant.

Constraint: this is one of the major ways for what service users become dependants. It can cause threat as they may be forced to think as other people think. Mrs. Ellen was not forced to do anything while staying in the care home. She was encouraged to perform her all day to day activity and as a result she become a role model in that care home. Basically, adults should be assisted to carry their day to day activity but not doing the total thing for themselves. They may think about their inability but they should be encouraged to work by themselves assessing the risks. Otherwise, they will be dependant, frustrated and will lose their taste of life.

2.2 Processes and support mechanisms to maximize independence and choice for individuals like Ellen

Sussex & Scourfield (2004) describe that empowerment of social, physical, emotional needs, intellectual factors, access to information, maintaining confidentiality, participation in decision-making and choice can maximize the independence and choice for individuals. These are given below:

Promoting rights of them. For example, letting them to maintain their confidentiality, safety and security
Allowing them to take risks. But risk must be assessed. If that can cause severe problem, they might be encouraged restrain from certain things.
Allowing them to communicate and make relationships with anyone that they want.
Allowing them to individualised care, involving responsibilities etc. Everyone has responsibility not to infringe on the rights of other people.
Individuals must be given chance to take their own decision and make choices for them.
Individuals will get full access to gather information.
They must be given right to carry out their religion and cultural activities.
Providing a range of options from which they can make choices
Encouraging them to solve problems in the future on their own successfully.
2.3 Organisational systems to promote participation and independence for individuals

According to Sussex & Scourfield (2004), empowering individuals potentiality, ensuring performance of workers, proper guidelines and inspirations to work by own initiatives, staff training, getting feedback, inspection and opinion sources of information for each and every individuals can be a few examples to promote participation and independence for individuals by organizational systems. These are described below:

Empowering individuals: Heumann et al (2001) state that, each and every employee of any organization may be promoted to participation and independence by empowering their sleeping potentiality. According to him, the development of service delivery and service quality may be increased significantly by the empowerment of employees’. To implement this, proper guidelines to let them work by themselves will be necessary. Thereafter, they can be told the benefits so that they can realize the necessity of the empowerment.

Ensuring performance of individuals: Huber (2006) has shown that, organizational participation can be developed by ensuring performance of individuals. The organizational management will make sure that all the employees are up-to-date with changes so that they can perform in a better way. When they will find out their good performance, they will intend to take part extra organizational activities and feel free to work independently.

Sources of information: Employees from all the organizations should have free access to information so that they can solve their basic problems by themselves. In addition, they will know the pros and cons of the organization. As a result, they will think themselves as an individual and important part of the organization which results them to participate and involve throughout the organizations. (Anderson & Aydin, eds., 2005)

2.4 Tensions that arise when balancing the rights of the individual to independence and choice against the care provider’s duty to protect

According to Thompson et al (2006), there are many factors which cause dilemma while providing care to the vulnerable adults e.g. Safety vs. independence, safety vs. rights and responsibilities of individuals etc. For example, if patients with dementia or frail people want to go somewhere by themselves, then care providers’ are in trouble. People with dementia may loss their way and find it difficult to retrieve it. In addition, they can cause harm to others and themselves by their aggressive behavior. Frail people may fall down easily and cause serious harm to them. So, the relatives or even the person himself/herself may complain against the care providers when they are in trouble. Considering these factors, care providers are reluctant to let them do anything which can harm their clients. In the same time, each and every individual has right to live independently but it can cause conflict between relative vs. client, client vs. employee, employee vs. relative, children vs. parent, parent of children vs. service providers and staff vs. staff. Thus, tensions can arise while balancing the rights and choice against the care providers’ duty. Overall, care providers will first consider and ensure their clients’ safety and then independence.

Question 3
3.1 Identifying and explaining risk of abuse or harm from the case study through the case study.

From the given scenario, we have seen that Mr. Simon was abusing eight elderly clients in his care which affected his client’s very badly. His clients’ might have to face (opuronio) loss for that abuse. Now the risk of abuse and the way they could be harmed are given below:

It has been said in the scenario that one of the lady who is aged 78 years old was poured cold water and stocking over her head. Researchers have shown that cold water during shower helps to get good health for the normal aged people where it harms elderly people. According to Thygerson (2007), it can increase the risk of heart attack. Putting stocking over the head can choke the lady and lead to death. It can cause paralysis as well.

Mr. Simon also harassed sexually one of the elderly ladies who are 92. It is really matter of shame and strong sexual abuse against that lady. That lady must feel very ashamed that can lead her to suicide. Also, she can be injured seriously physically as body structure becomes very sensitive at those ages.

Obviously it is illegal and humanistic to force anyone to do anything though sometimes that can be good for the person. Anyone can be requested to do anything but is up to the person to accept any help or service or whatever. A 96 year elderly client was forced to eat her food though she was reluctant. Also, Mr. Simon poured sherry into one of his client’s throat who was 81. that could cause her choke. As a result, she might die. It could also cause her vomit which can lead to loss of appetite. She was being physically abused during her care.

Without this, as many of his clients’ were suffering from senile dementia and psychological problem, they might not remember what happened to them during their care and might think whatever has been done as a part of their treatment! This is a clear indication of physical and mental abuse. Physical abuse was acute for the clients who were wheelchair bound because they could not either protect him or take themselves in safe position quickly. In addition, their privacy, self esteem, dignity, choice, respect, safety have been neglected instead of giving them appropriate care.

3.2 Options to protect individual from abuse whilst balancing legislation requirements and guidance with the tensions involved

According to Pritchard ed. (2008), there are some legislations and guidance to protect and safeguard of the vulnerable adults in the UK. Among them human rights act 1998, Disability discrimination act 2003, Protection of Vulnerable Adult (POVA), Care standard act 2008 are the most effective acts to ensure the safety of vulnerable adults and protect them from any kinds of harm. The scenario has shown that some of the clients’ were being abused mentally and physically during their care though they were staying in a nursing home. Basically, abuse can happen because of lack of proper implementation of national legislations. According to the legislations, vulnerable adults may be suggested to stay in their own home or care homes or nursing homes or hospitals in accordance with their health condition. But risks must be assessed before taking any decision. In addition, clients have the right to choose any types of service they need for. They can also refuse all the services as well if they want unless they are mentally handicapped. Thus individuals can be protected from abuse at the same time as balancing legislation requirements and guidance.

3.3 The effectiveness of policies, procedures and managerial approach for promoting management of risks for a known setting

According to Torrisi & Hansen-Turton (2005) and Kemshall & Pritchard (1997), every organization should have some organizational policies, procedures and managerial approach of their own to run their business effectively and to gain their goals easily along with national policy, procedures and laws. For example, a nursing home should have some legislations regarding acceptable and unacceptable risk, protection from unacceptable risk, assessing and recording risk, participation in creating abuse-free environment, complaints procedures, leadership style, whistle blowing policy along with national service standards. Among them assessing risk, leadership style and complain procedures are significant to promote management risks. A nursing home must have adequate equipment to deal with patients. In addition, early identification of possible abuse, screening of people who are going to start work, reporting to people with proper procedure, getting feedback and opinion from clients, keeping as eye and proper monitoring system of the client’s finance, psychological and physical issues can also promote management of risk.

3.4 Justify recommendations for improving management approaches to managing risks of abuse in the setting of the case study

Parsloe (1999) and Messer & Jones (1999) have shown that, the management can play an important role to manage the risks of abuse. Some important recommendations are given below to manage risk:

A care worker may be monitored or supervised by an authorized person while providing care.
Screening of people will help to obtain an employee’s mentality about his/her job role.
Getting regular feedback from client will disclose the quality of service that they are getting. So, staff will try to give their best to achieve reputation which will minimize risk.
Having necessary equipments cut the danger of life respectively. For example, a service user may need to be transferred for emergency. In this case, having ambulance facility is a plus point to cut risk and abuse of treatment.
Stealing, creating psychological or physiological harms are the cases that happen in care homes, nursing homes or in hospitals. So, monitoring of employees’ will help to manage risk of abuse as well.
Question 4
4.1 The legislation, guidance, codes of practice and policy that apply to the handling of medication

According to Association for Real ChangeA (ARC) et al (2006), there are some particular laws, legislations, guidance and policies to handle medication as well as it’s ordering and maintaining, administration, storage, recording, and disposal. These are Drug act 2005, PoisonsA and Therapeutic Goods Act 1966 No 31, PoisonsA and Therapeutic Goods Regulation 2008, Public Health (General) Regulation 2002, Medicines act 1968, Drug misuse act 1986 etc.

These laws and legislations have described the management and supervision systems for the administration, storage, disposal and recording of medication. According to a new law, a registered nurse (grade 1, minimum) must handle the administration of medication to ensure the standard of care in the care homes. In addition, it provides safeguards for the administration of medication along with personal care attendants and in the hostels.

Medicines act 1968 has provided a legal framework within which doctors, surgeons, pharmacists, suppliers and nurses are able to administer medications. According to this act, there are some medicines which are restricted to sale, supply and administration. A drug handler must have to have license to prescribe or dispose any medicine. They also have to renew every licence granted under this Act, unless previously renewed or revoked or will expire at the end of the period of five years from the date on which it was granted or the date as from which it was last renewed.

Drug act 2005 and misuse of drug act 1986 have provided very strong law to handle and protect the misuse of drugs. According to this act, a supplier of drug has to prove that, it has a valid intention to provide drugs. Court can assume against a supplier for abusing drug if they can find out less amount of drug than prescribed. In addition, an issue can be raised if the accused may not have had the drug in possession with the intent.

Thus these legislations, guidance and policies help to safe handling of medicine.

4.2 National service standards to promote safe practice in the handling of medication

According to Crouch et al (2008), today’s medicines are powerful compounds to control disease, ease discomfort and prolong life for millions of people and are generally beneficial. But nothing in the world gives us only blessings. Almost all the medicines have got side effect to human body. This is why, national standards, legislation, national enquiries e.g. the Shipman Enquiry, ethical issues, service user choice, acceptable risk etc. have been introduced to minimize the risks and promote safe practice of medication.

Another author named Railton (2007) has stated that, all the clinicians, doctors, nurses, care workers, pharmacists have to meet national minimum standard while handling the medicine. For example, a practitioner must have to have a valid license for practicing or prescribing medicine. According to McGee ed. (2009), some of the key principles to promote safe practice are given below:

Clients of social care services have freedom to choose concerning their provider of pharmaceutical care and services including dispensed medicines.
Care staffs have to be aware of medicines that each client has and a complete account of medicines will be recorded by the social care service.
Care staffs help people with their medicines have to be well-trained and competent.
Medicines must be given correctly and safely, and care staffs have to preserve the privacy and dignity of the individual while giving them medicine.
Medicines should be available when the patient/client needs them and the service provider will make sure safe disposal of unwanted drugs.
Medication orders must be timed; dated, signed and handwritten orders must be readable.
Only approved hospital abbreviations will be used.
Medicines must be stored safely.
The social care service will have an access to advice from the pharmacists.
Medicines have to be used to cure, prevent disease and to relieve symptoms.
Medicines can not be used to punish or control behavior.
4.3 Evaluating the effectiveness of policies and procedures for administering medication to achieve best possible outcomes for service users

Thomas et al (2003) has shown that the policies and procedures help to achieve the best possible outcome for administrative medication and care homes are one of the examples of it. He shows that, care homes reduce the risks of medication by following the policies and procedures. As a part of medication administration policy, now they keep all the records of medication to avoid future risk. Sometimes they check or review the side effects of any drugs in the internet and discuss with any third party if necessary. According to Thomas et al (2003) and Boon et al (2006), effectiveness of policies and procedures are given below:

Each and every written order for medication must state the names of medication clearly which have been ordered. They also mention the dose, the time of any medication is to be administered, route for administration, the reason of the prescribed medication. In addition, any specific time of medication or the first dose is to be considered for administration. So, there will be a rare chance to cause any mistake will lead a good outcome for the patients. Because of the changes in policy nurses are no longer allowed to gather information or obtain the medication from the night locker unless a pharmacy is available to dispense the medication. So, misuse of drugs will fall down. In addition, only hospital approved abbreviations are being used in prescriptions so that clinicians and medical professionals can understand those without any difficulty. It saves time and care service is becoming fast. Violence and silent punishment by the medication in the care homes have been stopped as medicines are not allowed to punish or control behavior.

Harrison (2006) has shown that about 7000 deaths are occurred every year. But now the number has been decreased significantly after the full implementation of medication administrating throughout the care homes, children homes, nursing homes and hospitals. It also ensures the safe practice of care by providing a guideline to the responsible persons by giving idea about right dosage, right medication, right time, right patient, and right route. Thus medical administration helps to achieve the best outcome for the service users.

In this essay I am going to write about vulnerable adults, how I could demonstrate professional values and how I could empower vulnerable people demonstrating respect and maintaining dignity. I will demonstrate an understanding of legislation and policy guidance, noting the strengths and weaknesses in accordance to NMC code of conduct. I will also briefly give the history of abuse, bringing in various Department of Health documents as clarification to demonstrate the need for current legislation regarding the protection of vulnerable adults. I will discuss how the ability to support my chosen case study and careers is seen as the key skill of the nurse, which requires a non judgmental approach which is essential to working in an anti oppressive practice. Definitions of vulnerability and anti discrimination will also be included as it is a comparison of NMC code of conduct.

Vulnerable people all are very sensitive to the need of their independence and they can be vulnerable very easily for instance if they are in pain. So nurse should always understand how the impact of loos, change or grieving processes can affect the individual. I have chosen adult case study two which is Mamoun. He is vulnerable because, he has had an operation and he is in a lot of pain. Mamoun doesn’t talk about the pain or ask for painkiller but if offered, he will take them.

VULNERABLITY – Vulnerability is people when support is required to enable or promote independent living and safe and active participation in the Community. To a certain extent some people or groups may be vulnerable because they perceive they are vulnerable e.g. if they believe they live in a high crime area when that is only a perception and not a fact. Iliffe.s et al (1998). Social exclusion is a process in which social, economic and cultural factors can combine to exclude individuals, groups and communities from participating in society and gaining access to economic, cultural and social resources. When combined, they create an acute form of exclusion in particular neighbourhoods. Having identified those groups who might be vulnerable the next stage is to decide the best means of helping them. The Evaluation Panel believes the primary aim should be to give vulnerable people as much control over their lives as possible to mitigate the circumstances that make them vulnerable. Parker.J. (2006)

A vulnerable adult is any person aged 18 or over who is or may be in need of community care services because of disability, age or illness, and who is or may be unable to take care of themselves, or is unable to protect themselves from significant harm or abuse. Vulnerable adults could include older people, people with a visual or hearing impairment, physical disability, learning disabilities or mental health problem, and people living with illness. Vulnerability can also be described as “unprotected, unguarded, open to attack, helpless and weak” Oxford. (2002). in another way if anyone walks at night in dangerous area we all tend to be vulnerable or able to be hurt.

Mamoun is a sixty two years old Muslim man who is based on in so much pain after his operation and he is vulnerable because he is isolated from his religious or cultural activities. He may have nobody to talk to or no family to visit him as well as language and culture problem. Mamoun may experience from a very limited health care service or he may not happy the way he treated which can make him more vulnerable. So even though he doesn’t answer questions politely and never ask for PRN pain relief, it is the responsibility of nurses to give full attention and see his reaction of his pain. When I am on my duty, I must make sure that he is in a good condition by checking him all the time. If he is in pain, it shows when looking at him so it is impossible to wait for him to ask for pain relief. Mamoun may has no idea about medicines and he is unable to talk it may be lack of communication skills or language problem. Having said that I could look in different way for example, get interpreter, being nice, friendly, kind, understand his pain and make sure that he trusts me.

According to NMC cod of conduct the following professional values will inform and guide all work with vulnerable adults: “Treat people as individual” – avoid discriminatory in any way against the patients, treat kindly and act as an advocate NMC (2008). Work effectively with a team – able to be flexible within teams, respect and support each other. Privacy – the right of individuals to be left alone or undisturbed, and free from intrusion or public attention into their affairs. Dignity – all people will be treated with respect. Each individual’s unique characteristics and intrinsic value will be recognised. Independence – the right to act and think without reference to another person. Choice – the opportunity to make both small and more significant life choices, with assistance as appropriate to understand context and options; the opportunity to make choices in the individual’s own interest, exercising the choice to take risks Laverack.G. (2005). . Rights – the maintenance of all entitlements associated with citizenship, including full participation in the life of the community Iliffe.s et al (1998).

Abuse against vulnerable adults has been noted since the 1960’s, although certain types of abuse would have taken place before then, society has changed and what is acceptable now is certainly different to what was acceptable back then. People became quite vocal in the 60’s, more open minded and speech and opinions flowing freely an example of this would be the topic of sex and drugs. Iliffe.s et al (1998). Abuse is a violation of an individual’s human and civil rights by another person. It may consist of a single act or repeated acts. It may be planned or unplanned. It may be the result of deliberate intent, negligence or ignorance. It may happen when a vulnerable adult is persuaded to enter into a transaction to which they have not consented or cannot consent.

Abuse besed on many forms some of them that more comenly knowen are include: Physical Abuse – for example, hitting, pushing, and shaking over medicating or otherwise causing physical harm. Sexual Abuse – for example unwanted touching, kissing or sexual activity. Or where the vulnerable adult cannot or does not give their consent it mayt be. Psychological / Emotional Abuse – including verbal abuse, humiliation bullying or the use of threats Iliffe.s et al (1998). Financial Abuse – the illegal or improper use of a person’s money, property, pension book, bank account or other belongings. Neglect – the repeated deprivation of help or care that a vulnerable adult needs which, if withdrawn, will cause him or her to suffer. Institutional Abuse – abuse, neglect, withdrawal of rights or continually poor care in a care home setting. Discriminatory Abuse – Including racist or sexist abuse, and abuse based on a person’s disability, and other forms of harassment, slurs or similar treatment.

Abuse can take place in their own home, by familly or any other visitor, or in someone else’s home, by a relative, friend or neighbou, in a residential or nursing home, by a paid or volunteer carer, in a day centre, adult education centre or other establishment, by an occasional visitor or service provider, in a hospital or GP surgery, mayt happen by a professional worker.

ANTI-DISCRIMINATERY – Anti-discrimination practice is a positive action to avoid discrimination. It is abut being presenting positive image of people equal opportunities policy in all aspect programs that take place and also challenging any discriminatory or oppressive language and behavior Parker.J. (2006). There are different tyeps of discrimination, such as more commonly known, racism, disablism and ageism. One of the things we do when meeting people is to make assumptions about them which can make them more cnfortable. Discriminatory language often betrays assumptions that have not been based on accurate knowledge or on cultural stereotypes. Often it emphasises the superiority of the speaker or the groups that she/he represents. This need not be conscious for it to be offensive and exasperating. Non-discriminatory language promotes exclusivity by the deliberate attempt to ensure that the language used promotes the equality of all people Parker.J. (2006).

The role of training is always to ensure that the maximum number of people possible have access to the information they need. Particular intention must be given to avoiding the use of technical language and jargon. Workers have an obligation to ensure that everyone who can benefit from their service has an opportunity to access it, and whilst they are using it, to be treated in a way that accords their need for decency and self- respect Laverack.G. (2005). As a trainer to model good practice, I have to be serious about my responsibility to ensure that the patients have an opportunity to participate in the event and achieve their maximum learning potential. I also need to have good practice how to speak in appropriated language and behaviour. It is very important to make an action plan for acceptable language and behaviour as a professional. All trainers must avoid using language or behaviour that is in any way discriminatory.

Mamoun may be increased risk due to the unaware of his rights, socially isolated, not know how to complain and has communication difficulties. He may also has difficulty understanding certain decisions or transactions and may have limited life experience and find it difficult to anticipate. In this case, there are different kinds of things to think about such as development of social networks – keeping in contact with family, friends, and neighbours as he is isolated. I will encourage him to access to social groups which may help him to make friends. Access to support groups I will get interpreter for him if he has language problem. Support and advice, I will support him in caring for him and I will advice him to tell as his problem in order to improve and maintain his health. Assessment of needs, as I mention on the above for client who is unable to talk I will assess by psychologically understanding for example, watching the patient if any behaviour or act change think about his food and asking of his needs.

REFLECTING – From this essay, I have learnt a value of social work for instance philosophical and academic thinking in order to assess client’s needs and circumstances. I have also learnt the role of NMC code of conduct and I have developed skills and professional knowledge to work effectively with vulnerable people. The NMC code of conduct helped me to understand how the laws and policies were applied to these such good example cases. Adult Case Study 2 was a unique case for me as although the service user did not have any mental health needs he required help with foll servisce. This essay teaches me the aspect of nursing I can reflect on, the use of the word experience in nursing, how self awareness is central to reflection and how the development of other skills will aid reflection.

In the future I believe that I will be able to demonstrate and work closely with both service users to support them, by assessing their needs, reviewing risks, policies and procedures that apply to them. This essay will help me make my work clear to service user and also more open to review so I can improve my practice in the future.

The purpose of my research is to show how to empower domestic violence victims to prevent them from or remaining becoming victims. I satisfy this purpose by recognizing the signs of domestic abuse by the abuser, examining the history of domestic violence and, statistical data; I also address the enabling friends, family to recognize the symptoms of the abused.

Domestic Violence is an assault on an intimate partner with most violence committed against women by their male partner (ABA, 2010). Many programs have been introduced to communities as well as states to protect victims of domestic violence and their children. Women are forced to leave their lives behind taking the children with them to shelters or Child Protective Services take them, due to the abuse and instability in the home. Battered women shelters have been opened in an attempt to keep the women and children in hiding from their abuser. Often the victims and their children will move to another state in an attempt to be safe from the abuser. Children receive counseling and often suffer depression, aggressive behavior, and development of adult health problems (APA, 2010).

Domestic violence seems to be more focused on the victims than the batterer, resulting in having programs to protect the victim. Some examples are battered women’s shelters, and receiving assistance from programs to protect victims from the batterer. For the batterer, abusive acts are a control issue and batterers are determined to keep that control over their victims sometimes, leading to stalking and murdering their victim for the ultimate control and power (NCJRS 2005).

American society exerts a lot of time and money into programs to assist battered women and children who are witnesses of the violence. Society needs to look at the offender in an attempt to

understand the offenders’ reason for the violence, to study their main objective and why the abusers ultimately have no control over themselves.

Literature Review

Devaney (2008) reported a study conducted on children who were in long-term and complex needs because of experiencing domestic violence. His research revealed that professionals have an awareness of domestic violence, and that younger children with younger parents are most likely to experience prolonged periods in the child protective system. Devaney contended that government policy and professional practice should primarily be concerned with assessing the risk that men present, rather than the risk children and families experience. By reframing professional interventions, men are more likely to be challenged to accept responsibility for their behavior.

The domestically violent patients are more unstable from psychological viewpoint but not more inclined to anger than the average male. When comparing domestically violent patients with generally violent patients, domestically violent patients’ score lower on anger disposition and on aggressive behavior than the generally violent patients did (Kraaimaat, 2008).

According to the American Psychiatric Association (2010), abusers use many ways to isolate, intimidate, and control their partners. Abuse starts slow and may be difficult to

EMPOWERING DOMESTIC VIOLENCE VICTIMS 5

recognize. Initially the abuse is manifested in isolated incidents for which partner’s expresses remorse and promises never to abuse again. The abusers justify their actions because of stress or claims the abuse was something the victim did or did not do. Domestic Violence can lead to other common emotional traumas such as depression, anxiety, panic attacks, substance abuse, and posttraumatic stress disorder. Abuse can trigger suicide attempts, psychotic episodes, homelessness, and slow recovery from mental illness (APA, 2010).

Uncovering battering men’s attributions are important in understanding domestic violence, and these attributions are the key to curtailing domestic violence. What is common to these attribution styles is the evasion of responsibility for commission of, and for the need to take action to stop the violence. These attributions styles have been found to increase battering men’s hostility and stress, their risk of engaging in violent behavior, as well as enabling the batterer to continue their violence unchecked (Wallach, 2008).

National Criminal Justice Reference Service (2005) reports power and control are fundamental concepts in the patriarchal family structure and in the relationship between violent men and their female companions; power-control theory may explain the response of the criminal justice system to woman battering. Power-control theory suggests that men batter

women because unless they are in control of their production sphere, and consumption sphere, the potential upset of the family’s balance of power is a real threat to the batterer.

Bostock (2009) reports that situations of domestic abuse can be prolonged by limited options available to victims of support and protection, and a lack of active public

acknowledgement that domestic abuse is unacceptable. Some women felt that the police still adopted and attitude of “it’s just a domestic” and that they did not take the matter seriously or offer effective help and protection.

Stoops (2010), study explores the existence and predictive ability of a behavior-based typology of men who were adjudicated for domestic violence crime in an urban criminal justice system. Results revealed that preliminary support for the development of typological assessment in criminal justice and early settings for early identification of men who may need additional intervention. Early intervention could prevent further escalation of violence from the batterer.

McCloskey (2004) presents information on the characteristics of a clinical population of male perpetrators of intimate partner violence court-ordered for batterer’s treatment, and how those characteristics co-varied with treatment attrition. When treating male batterers who were court-ordered to receive treatment, findings suggested that batterers’ self-reports of their own violent behavior were found to vary by data collection technique, with face-to-face interviews eliciting greater admission of violent behavior than paper-and-pencil questionnaires.

Domestic Violence Awareness Handbook (2010) reports that too many people continue to believe that domestic violence is a private matter between a couple, rather than a criminal offense that merits a strong and swift response. Even today, the victim of a domestic assault runs the risk of being asked, “What did you do to make your husband angry?” This question implies the victim is to blame for this abuse. People in the criminal justice system A??? police, prosecutors, judges, and jurors A??? need to be educated about the role they can play in curbing acts of domestic violence.

MayoClinic (2010) reports that even if a child is not abused, simply witnessing the domestic violence can be harmful. Children who grow up in abusive homes are more likely to be abused and have behavioral problems than are other children. As adults, child witnesses are more likely to become abusers or think abuse is a normal part of a relationship. Victims worry that seeking help will further endanger them and the child, or that treatment may break up the family. It was stated that treatment is the most effective measure to protect the child.

Discussion

During the research, my goal was to try to understand the actions and attributes of the batterer, in an attempt to make victims recognize the signs of a batterer before abused women become a victim. Another goal was to recognize the symptoms of the victim. The gathering of information provides an understanding of the abuser, and recognizing the warning signs of an abuser before they become a victim. Education of younger adults assists and informs families and friends of the trend of an abusive relationship.

Recognize Patterns of Domestic Violence

Domestic violence is a serious threat for many women. To be empowered, the victim must recognize the signs of an abusive relationship and how to leave a dangerous situation to achieve empowerment. Threats, including violence, suicide, or taking away the children are common tactics employed by the batterer. The existence of emotional and verbal abuse, attempts to isolate, and threats of and intimidation within a relationship may be an indication that physical abuse is to follow (MayoClinic, 2010). Knowing the signs of an abusive relationship is not only imperative for the victim, but is also an important weapon against violence for the victim’s

family, friends, and co-workers. The more people that are aware of the attributes of an abuser the less likely the relationship will develop into a domestic violent relationship. The victim is not alone and will not have the feeling of helplessness, or the shame of blaming herself, and will not deny the abuse if the ones that are close to the victim can recognize the signs. Victims will not feel alone, and will break the cycle early.

Education of Community Family, and Friends

Strict new laws are one way to reduce domestic violence, but education could prevent it violence or abuse from starting or escalating to the point of the victim being battered. Education should begin in the high schools for all students on domestic violence awareness to ensure that all members of the community are aware that domestic violence is not a private matter between a couple, rather a criminal offense that merits strong and swift response. Communities must take an interest to promote and educate on the programs that are available to the victims, such as hot lines, police, social workers, and battered women’s shelters.

Awareness needs to be brought to medical professionals who see the victims of violence who ask them about the crime, and seek more information rather than allowing the victim to fabricate an excuse for the batterer. Neighbors must contact the police when they hear violent fights in their neighborhoods. Teachers should be alert to signs that students have witnessed violence at home, or by a partner. Friends need to be educated that it is not the victims fault and assist in anyway, recognizing that abuse is unacceptable. The friends and family of the victims need to understand the needs of someone experiencing abuse. The longer a victim stays in

an abusive relationship, the greater the toll on the victim’s self-esteem, resulting in depression or anxiety. The victim may begin to doubt their ability to take care of themselves or wonder if the abuse is their fault and feeling helpless or paralyzed to act.

Break the Cycle

The longer an abusive relationship continues, the greater toll it takes on the victim’s self-esteem, but the cycle must be broken before the batterer gains total control. The cycle can be broken by telling friends, family or calling a domestic violence shelter, but must be done in a safe location. Victims should be prepared to leave, pack an emergency bag that includes items that the victim needs when they leave, and know exactly where to go and how to get there. The only way to break the cycle of domestic violence is to take action and the sooner the better.

Conclusion

Too many people continue to believe that domestic violence is a private matter between a couple, rather than a criminal offense. Even today, the victim of a domestic assault runs the risk of being blamed for the abuse, as if she is the one that brought on the assault. People in our criminal justice system A??? police, prosecutors, judges, and jurors need to be educated about the role they can play in curbing domestic violence. Nearly thirty percent of all female homicide victims were killed by their husbands, former husbands or boyfriends (Domestic Violence Awareness Handbook, 2010).

Strict new laws are one way to reduce domestic violence but nothing sends a clearer message to a batterer than prosecuting and jailing other batterers. New laws are not the answer if people are not educated in the system to enforce the laws. The victim often feels alone in the

situation, and as a society members must let victims know that they are not alone. American society must take action to let the victims know they are not alone.

Even when cases are brought to court, domestic crimes are difficult to prosecute. All too often victims are so terrorized that victims fear for their lives if they call the police. Silence is the batterer’s best friend. Members of the community, needs to end their silence and change the attitudes toward domestic crime.

EMPOWERING DOMESTIC VIOLENCE VICTIMS 11

There is “no health without mental health” (Ki-Moon, 2010, para.2; World Health Organisation, 2005, p.11) and this is why this topic has become at the heart of many discussions. The World Health Organisation (1948) in WHO (2003), approaches this concept holistically and defines mental health as the balance between all the aspects of life; “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity” (p.100). Barry & Jenkins (2007) add that mental health is an attitude that fosters in the individual a sense of control, hope, optimism and the capacity to build and sustain relationships in the society. Thus, mental health is said to be “a measure of how people, organizations, and communities think, feel, and function, individually and collectively (Keyes, 2007, in Mc Collam, Mukkala, O’Sullivan, Rowe, & Stengard, 2008, p.6). For this reason, Phillips (2008) affirms that the

well-being and mental well-being, in particular, [are] a new frontier in the fight for social justice in the creation of a society which is fair; communities which offer the individual dignity and respect; the evolution of a people confident in their diversity.

Given that mental illness has become the leading cause of disability in the European Community, with more than 130 million people expected to experience some kind of mental illness in their life (EUFAMI, 2004), many nations are acknowledging that they cannot ignore mental health and mental illness in their communities and workplaces anymore. As Gauci (2010) argues, countries that adopt “legislations, policies and systems that protect vulnerable citizens, including people with mental illness reflects a society that respects and cares for its people” (p.7).

Extensive is the research carried out about mental illness, but for a common terminology of the different types of disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM) has been developed. The DSM-IV states that

mental disorders are conceptualized as a clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.

(American Psychiatric Association, 2000, p.xxxi)

Thus, for behaviour to be considered a disorder, it must be originally caused by a “behavioural, psychological, or biological dysfunction in the individual” (American Psychiatric Association, 2000, p.xxxi). Conversely, expectable responses to particular events (e.g. the death of significant other), deviant behaviour (e.g. political, religious, and sexual behaviour), conflicts between the individuals and the society are not mental disorders. These only fall into the latter category when “the deviance or conflict is a symptom of a dysfunction in the individual” (American Psychiatric Association, 2000, p.xxxi), as aforementioned.

There is vast spectrum of mental disorders, each having their specific criteria, but for general use, Goldberg & Huxley (1992) categorize mental disorders in two ways, namely, common mental illnesses and severe mental illnesses. The former are mostly evident in the community whilst the latter refers to disorders which are more common amongst people who receive mental illness services and thus, contrary to the above, may need special care to convalesce. Goldberg & Huxley (1992) add that severe mental illnesses “are associated with much greater social disability and are much less likely to resolve spontaneously with time.” (p.5)

At this point it is important to understand that despite its severity, mental illness does not lead to mental disability, and the two are different from each other. As aforesaid, mental illness impacts a person’s behavior and feelings, however, the symptoms can be managed (Inclusion Europe and Mental Health Europe, 2007). On the other hand, mental disability, also known as intellectual disability refers to people who have difficulties in learning and understanding and whose skills “in areas such as cognition, language, motor, and social abilities can be permanently impaired” (Inclusion Europe and Mental Health Europe, 2007, p.2). Therefore, mental illness is not a disability, but the difficulties derived from the illness, can result in functional disability (Richmond, 2011). Functional disability is defined by the WHO (1976) as

disability in which functional limitation and/or impairment is a causative factor, is defined as an existing difficulty in performing one or more activities which, in accordance with the subject’s age, sex and normative social role, are generally accepted as essential, basic components of daily living, such as self-care, social relations, and economic activity.

(para. 1.2 iii)

2.2 Employment

In its simplest definition, work means the “exchange of labour for wages” (Danto, n.d, p.14). But employment has always had a higher value for humanity. Indeed the Ancient Greeks held that work formed part of the “sphere of necessity” (Haralambos & Holborn, 2004, p.619). Notwithstanding the changes and revolutions that the world went through, work still remained “a defining value of our culture” (p.12) and this is so because the need to work is deeply rooted in “our psychology and social existence” (Dante, n.d, p.14).

Work can take many forms but its benefits are rather homogenous. Cameron & Conley (2010, in Topp, 2010) assert that work is meaningful because it connects individuals to their values and to their community. It is also acknowledged that good working experiences affect the individual’s wellbeing and development, leading them to adopt more positive perspectives and attitudes. This is further reinforced by Finch & Moxley (2003), who declare that “employment offers much promise to people and is fundamental to their development as fully realized human beings” (p.10). Underlining all this is the truth that employment is a human right. Hence, all people “have the right to work; to free choice of employment; just and favourable conditions of work and protection against unemployment” (Article 23, 1948, in United Nations, n.d). In the convention on the rights of persons with Disabilities, the United Nations (2006) accentuate that people who experience disability are also entitled to “human rights and fundamental freedoms in the political, economic, social, cultural, civil or any other field” (Article 2) and discrimination is proscribed, including the failure to provide reasonable accommodations for those who need it.

This is sustained by Bassett & Llyod (1997) in Bassett, Bassett & Llyod (2001), when they claim that “involvement in paid employment is a significant life occupation for many people and is a realistic goal for people who have experienced a mental health disorder” (para.2).

2.3 The benefits of employment for people experiencing mental illness

Therefore, work is not only important to maintain good mental health but also to enhance the improvement of those who are experiencing mental health difficulties. “Enabling people to retain or gain employment has a profound effect on more life domains than almost any other medical or social intervention” (Boardman, Grove, Perkins & Shepherd, 2003,p.467). This is so because employment harbours inclusion, yields a sense of security, happiness and comfort; a sense of living needed for recovery. Recovery from mental illness is a reality nowadays and it has become a goal for many people. Recovery does not mean that symptoms disappear, but it is all about getting on with life beyond the disability (Deegan, 1988). Having experienced it herself, Deegan (1988) adds

recovery does not refer to an end product or result. It does not mean that my friend and I were ‘cured’. In fact our recovery is marked by an ever-deepening acceptance of our limitations. But now, rather than being an occasion for despair, we find that our personal limitations are the ground from which spring our own unique possibilities

(p.56).

Work is central to the process of recovery (Canadian Mental Health Association, 2005; HM Government, n.d). This is so because it provides both the financial means for living and also latent benefits. Olsheski & Schelat (n.d) assert that employment is beneficial because it provides structures to daily activities, an identity, a sense of achievement, socioeconomic status and a sense of belonging. This is sustained through Hertzberg’s theory who believed that work meets human needs in two ways. The acquisition of a salary, the working conditions and interpersonal relationships established at the working site make up the hygiene factors. According to Herzberg, their absence creates dissatisfaction in the individual, but does not lead him to feel satisfied and motivated (Herzberg, 1959, in Gawel, 1997). At this level, any changes towards job performance are only short-lived. Conversely, motivator factors produce long-term positive outcomes which appear to be a consequence of job satisfying events such as appraisals, achievements and advancements (Herzberg, 1959, in Gawel, 1997). Job satisfaction and longer job tenure have been found by Resnick & Bond, (n.d) in URBIS (2007) to be co-related.

As it is acknowledged above, the benefits of employment for people with mental health difficulties are various, yet the barriers for work are still a reality. In fact, people experiencing mental health difficulties rank low in employment when compared to other disabled groups (Organisation for Economic Co-operation and Development, 2009; Duncan & Peterson, 2007), despite that many of them have the aspirations to work (HM Government, n.d). In addition, Catalano et al (1990) claim that people with mental illness are many often employed in part-time work, characterized by little pay and possible insecurities. The reason behind this is that accessibility of the workplace most often is only associated with the adaptation of the physical environment through the use of various adaptive equipment, and adaptation of the social and emotional environment is often neglected. Accessibility also means opening up the labour market to facilitate participation in the economic activity and social functioning. While it is true to say that the illness often acts as an obstacle (Frado, 1993) and may create problems for the employee whilst in employment, but the working environment also lacks the tools to accommodate “their interests, abilities and support needs” (Bill et al, 2006, in URBIS, 2007, para.4.3.4).

Some of the most severe forms of mental illness have their onset in late adolescence and beginning of young adulthood, whilst others strike in middle adulthood. As a matter of fact, both a person’s education and working life could be significantly impacted; resulting in fewer credentials which are needed for employability and the disruption of employment for those who are already employed (WHO, n.d, in Richmond Foundation, 2011). Penrose-Wall & Bateman (2007) in URBIS (2007) add that people with mental illness may experience a downfall in their confidence, motivation and social skills as a result of the episodic nature of the illness, and as a matter of fact, their “employment is understandably disrupted” (para.4.3.1). Once again, a person’s educational and occupational attainment may be at a disadvantage (Robdale, 2008). Moreover, the level of severity of the illness has been linked to unemployment, with a percentage as high as 85% for people with severe mental illness (Crowther et al 2001, in Duncan & Peterson, 2007). Additionally, the medication used to treat the illness may pose some difficulties for the person whilst on the job. Some of which include drowsiness, tremors, blurred vision, nausea, agitation, bladder problems, dry mouth amongst others (National Institute of Mental Health, 2008). Despite the struggle to cope with the illness, people may also have to deal with bad financial issues that arise when their ability to work is affected. Thus in order to make ends meet, people with mental illness may force themselves back to work before they would have gained their health (Canadian Mental Health Association, 2005). In the light of such delicate situations, Cappe (1999) avows that

it is no longer enough to do the right thing, but we must also ensure that we are doing things right. It is no longer sufficient to be a place where people work-the workplace itself must be built around the people and give them the support they need

(para.1)

A place of work that is built around people is one that welcomes diversity. “It signals the enthusiastic acceptance of the value to organizations of workforces that are diverse in terms of gender, age [and] (dis)abilityaˆ¦ (Jackson & Joshi, 2001, in Arnold, Burnes, Cooper, Patterson, Robertson & Silvester, 2005,p.35). Mental illness is no longer a rare condition but it is has become one of the most common causes of disability with the World Health organization claiming that by the year 2020, depression will become the second leading cause of premature death and disability (Canadian Mental Health Association, 2005). In the light of these statistics, employers cannot fail to acknowledge the concepts of mental health and mental illness in their workplace. It is time to do away with the misconceptions that people with mental illness are violent and have low intellectual abilities. To the contrary, they are usually the victims of violence and their intelligence and abilities are not dissimilar to the rest of the populace (Frado, 1993). Many people experiencing mental illness are able to work, want to work and can carry out their job successfully (Cook & O’Day, 2006).

2.4 Stigma

But stigma has the power to erode this willingness. As HM Government (n.d) outlines, barriers to employment and sustainability of employment for people experiencing mental health difficulties are also found to be derived from society itself, with stigma acting as one of the major obstructions. Stigma can be described as

severe social disapproval due to believed or actual individual characteristics, beliefs or behaviors that are against norms, be they economic, political, cultural or social. It is characterized by a lack of knowledge about mental health, fear, prejudice and discrimination.

(Mc Daid, 2008, para.2.1)

These are also the prevailing beliefs amongst certain employers, who are still afraid to employ and support people with mental illness (Waghorn & Lloyd, 2005, in URBIS, 2007; Canadian Mental Health Association, 2005; Mc Daid, 2011). They may have “unwarranted fears and see persons with psychiatric disabilities as unskilled, unproductive, unreliable, violent or unable to handle workplace pressures” (Fenton & Payne, 2005, p.8). But mental illness does not always encroach with the worker’s job performance or it may affect the ability to work only for a certain time, during which, some limitations may arise (Frado, 1993). These may include “consistent late arrivals or frequent absences, decreased productivity, frequent complaints of fatigue or unexplained pains, difficulty concentrating, working excessive overtime and expressions of strange or grandiose ideas, amongst others” (Fenton & Payne, 2005, p.7). In view of these limitations, the untrained employer and colleague may fail to recognize mental illness, and interpret inappropriate behavior negatively, thinking that their work mates are violent, dangerous and erratic (Harnois & Gabriel, 2000). This is further manifested in incorrect and discriminating behavior as people with mental illness are often given insulting names, refusals by their colleagues to work with them and not considered for promotions (Fenton & Payne, 2005).

Just like students who tend to see themselves as ‘bright’ or ‘dull’ according to their teachers’ definition of them, people with mental illness may come to believe that they are truly ‘no good’. This negative general idea about mental illness is then often internalized within the individual himself, leading to self-stigma. Self-stigma refers to the negative feelings about oneself; manifesting itself into feelings of hopelessness, difference and unworthiness (Barnes, Duncan & Peterson, 2008). As a matter of fact, people with mental illness may not be so willing to try new job tasks, opportunities and promotions (Frado, 1993). The media is said to have a profound effect in all this. As findings indicate,

Coverage of mental health issues that was biased, negative, sensationalized, or incorrect was seen as contributing to the negative stereotypes that surround mental illness. These in turn influence the attitudes and behavior of the people who believe them, including people with experience of mental illness.

(Barnes et al, 2008, p.60)

2.5 Maintaining employment

In the essence of a holistic policy that targets mental illness, Maltese citizens who experience functional disability due to mental illness can in the meantime benefit from the provisions of the Equal Opportunities (Persons with Disability) Act (2000). In the light of this situation, Dr. C. Pace, social policy consultant and lecturer at the University of Malta, divulges that

while we clearly and strongly distinguished mental health problems from intellectual or learning disability, I think it would be a disservice to persons with mental health problems if we fail to tell them and society that, in the case of a long-term impairment, they can have specific and important legal rights.

(in a personal communication, January 2011, regarding how this was dealt with in a recent project)

Therefore, under the provisions of this article, people with a mental illness who exhibit functional disability are to enjoy the protection against discrimination as well as reasonable accommodations in their working environment. It is the latter concept which encapsulates the commitment of employment corporations to create the necessary structures, be them legal, administrative or institutional, which facilitate both employability and adaptability at the place of work for persons with mental illness. As the Transition Strategies, LLC (2010) contend,

Although the law prohibits discrimination against mentally disabled persons in the workplace, the economic impact of these numbers is so compelling that regardless of any concerns about disability discrimination lawsuits, employers cannot afford to ignore the problem. Even when a problem worker is fired, the odds are excellent that his or her replacement will be one of the remainingaˆ¦.The solution?

(para.2)

In view of these emerging needs, the workforce is pressured to understand that people with mental illness may have certain needs to be met. However this does not imply that their skills and capabilities are of a substandard (Boardman, Grove, Perkins & Shepherd, 2003). Employers and colleagues are suggested to increase their knowledge about mental illness and respond with anti-discriminative measures and reasonable adjustments so that people with mental illness can function in the working environment like their colleagues counterparts. Indeed, Frado (1993) claims that “the antidote to stigma in the workplace is for the environment to be positive, encouraging and welcoming” (p.6). However, there are people whose experience of mental illness does not affect their ability to work (Frado, 1993), and thus may not need help to maintain their job.

Accommodation measures are in effect some of the tools which the employer can use to help bring about adjustments to the workplace. “An accommodation is any change in the work environment or in the way things are customarily done that enables an individual with a disability to enjoy equal employment opportunities”, claims the U.S. Equal Employment Opportunity Commission, (2002, para.2). Research shows that that workers with mental health difficulties does not necessarily cause any excessive burden on the employer (Diksa and Rogers,1996; Tetrick & Toney, 2002) but with practical modifications in the social and organizational structure, they can act capably and competently in their work and as contributors to the society (Frado, 1993).

Starting a new job may be a stressful experience to people with mental illness (Mc Kee, 1996). This is so because they may be faced with certain challenges and thus may need accommodation to maintain the employment. In fact, Shankar (2005), states that keeping a job is more exigent than obtaining it. This is sustained by a personal disclosure of a person who says that

Because of my medication, it’s really difficult for me to keep to a schedule… I mean to get up on time. My employer is happy with my work and as long as I put in my eight hours, she doesn’t mind if I don’t make it on time every day. This is the first job I’ve been able to keep without being fired for lateness.

(as cited in Frado,1993, p.15)

People experiencing mental illness may find it hard to follow the demands of daily living such as waking up early but a positive and constructive principle like this provides a strong foundation for accommodation. Additional policies include allowing people to work flexible hours or to work at home, enable frequent breaks, allow workers to shift work hours to attend hospital appointments, allow telephone calls to doctors or others for support, and permit a self-paced workload amongst others (Loy, n.d).

A working place is not solely run by the manager, but people at different levels constitute different roles and all are important in the running of the company. Thus, even the attitude of the supervisors, colleagues and other staff adds to providing a climate that supports accommodation. Given that people still make negative connotations with mental illness, it is important to address these misconceptions by educating staff and colleagues about these illnesses, its course and consequences. Moreover, supervisors closely working with the employees should be given training on how to improve one’s approach and teaching methods. Examples include giving constructive feedback, offering praise and providing direction (Frado, 1993).

Nonetheless, in order for the employer to provide such accommodation measures tailored for the specific needs of the employee, people need to disclose about their difficulties but this is not an easy task given the stigma that exists. They may think that the advantages of disclosing about these difficulties are very little compared to the disadvantages and thus they may choose to remain silent. Others may have worked so much to restore their health that they do not want to be categorized as disabled (Frado, 1993). But as Mc Kee (1996) claims, the employee does not necessarily have to give a specific diagnosis of his illness. To the contrary, she suggests people with mental illness to “focus on how the disability impacts upon [their] ability to do the job and what positive steps can be taken to accommodate [their] needs” (p.7). Such a disclosure can potentially reduce tension whilst increasing support and help on the job. Employing people with mental illness is not only beneficial for their health but as the Canadian Mental Health Association, 2005 outlines, it also “bring[s] a new perspective to the workplace, and a new level of sensitivity among all employees to one another” (p.23).

The supported employment scheme is another benchmark in the commitment to provide people with mental illness the necessary services to find and keep employment. It was originally known as the place and train approach which embarked on the idea that people with mental illness shall first be placed in the job and then offered training (EUSE, n.d). The job coach has the imperative role to provide the service users with the necessary support to perform ordinary work requirements such as accompanying them to and from work, training and education of the employee, advocacy, assistive technology, behavioral training skills and other support to make the employment a positive experience both for the employee and the employer (Parent, 2004). The European Union of Supported employment defines this scheme as “providing support to people with disabilities or other disadvantaged groups to secure and maintain paid employment in the open labour market” (EUSE, n.d, p. 13).

Family members and friends may not be able to help in acquiring the skills needed for employment, but they can be a source of support and hope for people with mental illness along their working life experience. These social support networks are described “as a nexus of interpersonal ties consisting of family, friends, or other individuals who provide some type of support that leads one to believe that he or she is cared for, loved, valued, and belongs to a network with mutual obligations” (Milardo, 1988, in Pernice, 2010, para.2 ). These can aid in making long-term employment a reality (Canadian Mental Health Association, 2005) and recovery a lived-experience (Pernice, 2010).

2.6 The Social Model and Medical Model of disability

The measures outlined above are aimed to provide assistance for people with mental illness in finding and retaining employment in the mainstream workforce. However, as aforementioned, difficulties that arise in this scenario are not only a responsibility of the employee, but also of the society at large. Therefore this calls on the need to not view difficulties as the result of the individual’s disorder only; as anchored in the medical approach, but to also consider societal factors responsible for difficulties encountered (Mor, 2005). This is the social model of disability which “focuses on the complex ways that economic relations, cultural meanings, social practices, and institutional settings participate in the disablement of persons (Mor, 2005, p.22).

This shift in locus on the integration of people with mental illness in the society did not happen instantaneously. Although change in the beliefs, perceptions and attitudes towards mental illness seem to be taking a gradual pace, much improvement has been done along the years. Before the means of acquiring knowledge and information increased, people were not educated about mental health. This goes back to few centuries ago when mental illness was thought to be caused by supernatural forces. They were thought to be ‘moonstruck’ and thus were referred to as ‘lunatic’ (Pritchard, 2006, p.3). In fact, Mount Carmel Hospital, currently responsible of the rehabilitation of mental illness in Malta, was called the Lunatic Asylum in the 1800’s (Savona-Ventura, 2004). These perceptions of madness and possessions lead to the abuse of many people with mental illness. As Cauchi (1999) reported, people with mental illness were beaten and treated badly.

People with mental illness were made to believe that they were incurable and insane and were even denied civil rights (Daub, 2006). This is the medical model which rooted in its teachings has the basic ideology that mental illness is just a “chemical imbalance or a biological malfunction of the brain” (Daub, 2006,p.2). In this period, the mental health practice suggested that people with mental illness who were interested to work should stay away from working in the community. Instead, they were suggested to work in highly protected and isolated settings like the sheltered workshops (Becker & Drake, nd). These gave the individual “the opportunity to work without having to risk competition and failure experiences which, it was assumed, would occur in normal work environments” (Bussone, Cramp, Dakunchak & Rosen, 1993,para.2). Activities in this category were meant to shelter persons from normal problems while exposing them to normal task requirements such as time clocks and supervision (Becker & Drake, n,d). But as years passed by, sheltered workshops became less popular because work was demeaning and it offered no prospects since people always remained in an institutional setting (Bussone et al, 1993). Then focus was shifted on teaching people the necessary skills for employability. This was referred to as the train and place approach in which people mental health difficulties were given training in order to find employment. Once trained, they were free to find themselves a job. However this probability was not plausible since the acquisition of the skills alone were not sufficient to gain and maintain employment (EUSE, n.d).

The concept of supported employment was the last to be introduced but it is the one which offers much promise to people with mental illness as it emphasizes the need for integration into society and engagement in open paid employment. Whereas before, people with mental illness were only seen in the context of health services, now their strengths are being recognized and are considered to be potential contributors to our society (Frado, 1993). Supported employment schemes and accommodation measures both provide the employee with the opportunity to enjoy a working life that best meets their needs.

2.7 The Current situation

It could be that people are no longer beaten and retained due to their illness and sheltered workshops gain less endorsement, yet it is still a struggle for people with mental illness to find and keep jobs. As Gauci, (2010) says, “the lack of flexibility at the work place and the stigma and fears, which still exist in our society; most frequently results in the violations of people’s right to work”(para.5). Unfortunately, circumstances that defy the rights of persons with mental illness are not always given the prominence that they require (Gauci, 2010). Locally, supported employment services are very limited, even if they proved to be successful. In fact, the Richmond Foundation (2009), in Richmond Foundation (2011) asserts that in the year 2009, a total of twenty six persons with mental illness benefited from this scheme. This service has been unavailable for a period of time but is currently in the process of being re-introduced. Also, the Maltese mental health Act needs to be updated as it continuous to result in the violations of the rights of people experiencing mental illness (Ameen, 2009). To further stress this point, Mc Sween (2002) claims that mental health “still receives less government support than general health care” (para.1). Indeed, Gauci (2010) avers that

it is very basic and superficial when a country has policies and legislation which promote community care when in practice community services are inadequate, scare, uncoordinated, understaffed or staffed by persons who are not trained to deal with persons with mental health difficulties in the community.

( para.4)

These support lacking systems are also a major concern to many parents who fear that their children will become unemployed, poor and homeless, “with no one to look after them, rotting away and walking around the village looking dirty and alone”(Calleja, 2010b, para.16).

2.8 Social work and mental illness

Social Work has an imperative role in all this since its core values are crafted to address social problems and challenge social injustices (Johnson & Yanca, 2007). Not only should social workers provide people with mental illness with the support and skills needed to help them overcome disadvantage but also seek to transform the society for the benefit of their clients (Payne, 2005). This is so because the social work profession calls on its associates the need to consider the person in environment as sometimes “there is a tendency to ignore environmental factors responsible for social problems” (Johnson & Yanca, 2007, p.60).

It is this aspect of social work that moves in line with the social model of disability, as it too takes into consideration the society’s attitudes that act as a barrier for people with mental illness to maintain employment. Th

Social Work Practice, a powerful modern day skill for social empowerment of the disadvantaged and excluded segments of society, is an occupation of enormous scope and an immensely stressful activity (Burgess & Taylor, 2004).

Educated and trained in social work theory and practice, these practitioners are required to constantly interact, assess and understand situations, as well engage in various actions aimed at providing appropriate relief and succour to their disadvantaged clients (Burgess & Taylor, 2004). This calls for significant knowledge of the tenets of social work practice. However, social workers in the UK function in an increasingly management oriented setting which is more organisational and administrative, with an emphasis on private public participation, accountability and coordination (Burgess & Taylor, 2004, P 7 to 81). Increasing competition between social work providers, business-oriented standards for performance assessment, mounting work pressures and the need to micro manage and carefully control the distribution of services often lead to personal dilemmas, contradictory emotions and disorientation (Burgess & Taylor, 2004, P 7 to 81).

Significant failures in social work have brought to the fore various challenges facing social workers in processing and comprehending their own emotions and actions, as well as those of others (Perez-Koenig & Rock, 2001, P 25 to110). Modern day behavioural experts and psychologists feel that much of the reasons behind such failures lie in the inadequacies of traditionally followed training approaches, which deal primarily with the inculcation of practical and theoretical competencies and ignore broader and more holistic emotional issues (Perez-Koenig & Rock, 2001, P 25 to110). Adequate attention to emotional issues in the training and development of social workers is felt to be critically important for (a) aligning the emotional dimensions of social work, which, while essential, is rendered invisible, with the natural caring roles of social workers (b) providing supportive agendas for individual and professional development (c) providing processes to define the emotional constituent of social work practice that is obliterated by the increase of managerial practices in the area, (d) tackling the disruptive power of emotions on thought, (e) creating an effective balance between rational and emotional reactions for making of sensible and wise decisions, and (f) bridging cultural differences (Turner, 2005).

Whilst the origins of Emotional Intelligence (EI) can be traced back to the works of Darwin, its modern day emergence, as a serious and relevant issue for study and application in various areas of work that involve people, arose first with the work of Robert Maslow in 1960, followed by those of John Mayer and Peter Salovey in 1989. Peter Salovey described EI as “the ability to monitor one’s own and others’ feelings and emotions, to discriminate among them, and to use this information to guide one’s thinking and actions” (Nelson & Others, 2007, P 30).

The concept of EI received a boost with the work of the psychologist Daniel Goleman, who popularised it, first with his 1995 book “Emotional intelligence: why it can matter more than IQ” and thereafter through constant research and work on the subject (Nelson & Others, 2007, P 30). Goleman has developed a number of EI competencies in two specific areas of EI, personal competence and social competence, and has encouraged the inclusion of EI in the education and training module of social work (Nelson & Others, 2007, P 30).

This essay deals with the various ramifications of EI in social work and its use and application for fresh entrants, educated and trained in the area, principally in three specific disciplines; counselling, conflict management and social work practice,

2. EI in Counselling

New entrants in the area of social work counselling will be required to help people of various ages from different segments of society to confront and overcome a diverse range of problems and challenges (Payne & Shardlow, 2002, P122 to 198).

Counsellors aim to provide people with the guidance and support they require to alter their lives and move forward in a constructive manner. Social work counselling can loosely be segregated into (a) counselling and therapy (assisting clients with different emotional problems) (b) providing advice and information in areas related to jobs, employment choices, welfare, rights, debt, etc. (c) social and community care, (helping with providing of support to families, young and old people, and those without homes or with disabilities) and (d) charities and other voluntary organisations (providing support to workers to collect funds and organise volunteers in order to continue their operations (Payne & Shardlow, 2002, P122 to 198).

Recent years have seen an increasing conflict between the managerial and administrative functions of social workers and their requirement to meet individuals at the time of their need, give them respect, battle disadvantages and unfairness, construct relationships that resolve problems, and support wellbeing (Payne & Shardlow, 2002, P122 to 198). People in need of counselling have time and again requested to be treated with dignity and respect, to be patiently listened to and helped (Payne & Shardlow, 2002, P122 to 198). Effective counselling requires social workers to listen carefully, react effectively and build relationships with service users, colleagues and others (Payne & Shardlow, 2002, P122 to 198).

Goleman’s four core competencies, namely self awareness, self management, social awareness, and relationship management can be of immense help to new counsellors by enabling them to understand personal emotions and their effect on other people, as well as by developing the ability to control strong emotions that can upset service users (Druskat & Others, 2006, P 72 to 145). Inculcation of social awareness enables new counsellors to recognise the emotional condition of their clients, bridge cultural and social distances and understand the challenges and difficulties experienced by service users (Druskat & Others, 2006, P 72 to 145). Relationship management on the other hand equips counsellors to converse with service users, persuades them to listen to and understand the suggestions of the counsellor, and build strong bonds (Druskat & Others, 2006, P 72 to 145).

The principles of client centred therapy, popularised by Carl Rogers, require counsellors to refrain from unsettling clients with queries, evaluations, judgments, and explanations, but to focus upon providing secure, non-judgemental and caring environments, where the service users can control counselling sessions, decide what is discussed, and find their individual solutions to existing problems without requiring the counsellors to fix the course of therapy (Mulhauser, G, (2009, P 1). Carl Rogers based his framework on the belief that individuals become progressively more truthful and dependable once they realise that their subjective understanding is appreciated and accepted. Roger’s core conditions, better known as CUE, consist of Congruence, Unconditional Positive Regard, and Empathy (Mulhauser, G, (2009, P 1).

These three conditions are of extreme importance in client-centred counselling and new counsellors need to inculcate a deep understanding of them in order to provide requisite conditions for clients who have a strong desire to explore their feelings and who treasure personal responsibility. Such an approach may however be unsuitable for clients who wish to be provided with extensive advice, diagnosis of problems and analysis of their problems (Mulhauser, G, (2009, P 1).

“Clients who would like to address specific psychological habits or patterns of thinking may find some variation in the helpfulness of the person-centred approach, as the individual therapeutic styles of person-centred counsellors vary widely, and some will feel more able than others to engage directly with these types of concerns.” (Mulhauser, 2009, P 1)

Whilst newly inducted counsellors need to be careful about the requirement of their clients, the use of emotional skills is often necessary and needs to be fully inculcated by counsellors.

3. EI in Conflict Management

Social workers, especially those taking up positions in social work organisations, understand that their work will often deal with conflict and that too in various roles, as advocates, negotiators and mediators (Turner, 2005, P136 to 217).

Social work education comprises of a wide range of perspectives, (like environmental, radical and feminist), which in turn are based upon dissimilar premises regarding human relationships (Turner, 2005, P136 to 217). Social work practice requires different approaches from different perspectives in case of intervention for resolution or management of situations of conflict (Turner, 2005, P136 to 217). Examples of such situations (in terms of the above perspectives) could include interface between individuals and their social environments, confronting patriarchy, or challenging discrimination and oppression against a wide range of groups, including women, lesbians, gays and ethnic minorities (Turner, 2005, P136 to 217).

Conflict resolution training for social workers provides numerous principles for successful conflict resolution, like (a) the need for different responses for different conflicts, (b) the availability of different responses like avoidance, accommodation, competition, compromise or collaboration for bringing about solutions, (c) the need of people to feel secure from physical or emotional hazards, (d) the availability of various skills for conflict resolution skills like refraining, active listening, and identification of underlying interests, and (e) the need to balance emotions with rationality (Turner, 2005, P136 to 217).

Social workers are undoubtedly aware of the lack of emotional intelligence being the main cause of conflict (Lenaghan & Others, 2006, P 76+). Researchers in EI also argue that a lack of emotional intelligence is one of the leading causes of conflict in our society (Turner, 2005, P136 to 217). Contemporary training tools make significant use of Goldman’s principles on EI, particularly self-confidence, emotional self-control, transparency, empathy, motivation and relationship management (Turner, 2005, P136 to 217). “Goleman’s work makes a valuable contribution to conflict management theory and training, and a compelling case for the importance of emotion in what we believe to be ‘rational’ decision-making processes” (Bjerknes HYPERLINK “http://www.mediate.com/articles/bjerknes.cfm#bio”&HYPERLINK “http://www.mediate.com/articles/bjerknes.cfm#bio” Paranica, 2002, P1).

Goleman’s theories constructively help social workers understand the important role of emotion in life and the reliance placed upon emotional input for making decisions and prioritisation of information. This greatly helps in minimising conflict in personal and working life (Bjerknes HYPERLINK “http://www.mediate.com/articles/bjerknes.cfm#bio”&HYPERLINK “http://www.mediate.com/articles/bjerknes.cfm#bio” Paranica, 2002, P1).

“Solid training that focuses on developing awareness about our strengths and weaknesses as mediators, facilitators and trainers is crucial to our development as culturally competent process workers, and is crucial in our pursuit to help clients achieve their potential. Openness to learning and reflecting about our role, about who we are, and about how we affect others is essential and will lead us down the path to success in life.” (Bjerknes HYPERLINK “http://www.mediate.com/articles/bjerknes.cfm#bio”&HYPERLINK “http://www.mediate.com/articles/bjerknes.cfm#bio” Paranica, 2002, P1)

4. EI in Social Work Practice

Social Work practitioners are required to interact with service users, social workers and other participants of the social care system like medical practitioners, teachers and members of local authorities (Burgess & Taylor, 2004, P 101 to 172). With the interaction between social workers and service users being the focal point of social work practice, the relationship between social worker and service user involves perception on the part of the practitioner, appreciation of the emotions of the client and usage of perceptions to handle situations and achieve efficiency in delivery of social care (Burgess & Taylor, 2004, P 101 to 172).

Such work demands a high degree of emotional intelligence (Burgess & Taylor, 2004, P 101 to 172). Social work in the present context does not extend only to the assessment and fulfilment of perceived social needs (Burgess & Taylor, 2004, P 101 to 172), but also to the realisation of and respect for the service users’ goals, choices, and preferences and the use of interdisciplinary resources available with the social worker to meet their emotional, social, physical and economic needs.

Social workers need to engage in active introspection of events, try to obtain a clear psychological understanding of the challenges and needs of service users and inculcate genuine concern for the economically and socially disadvantaged and excluded (Burgess & Taylor, 2004, P 101 to 172). Whilst such perceptions cannot be generalised because of the different needs of different people, the inculcation of empathy and service orientation facilitates the development of necessary perspectives and perceptions (Burgess & Taylor, 2004, P 101 to 172).

Social workers entering practice should recognise that they need to confront their own emotions as well as those of their service users, especially so in cases where the issues are extremely challenging and difficult to resolve. Goleman identifies five EQ domains as (a) knowledge of own, (b) management of own emotions, (c) motivating oneself, (d) recognising and understanding emotions of other people, and (e) management of relationships, i.e. the management of emotions of other people (Druskat & Others, 2006, P 152 to 189).

Experts also agree that EI, along with reflective ability enables social workers to increase their resilience to stress (Druskat & Others, 2006, P 152 to 189). Self awareness and self management competencies help social workers to progressively develop self confidence, transparency, and optimism (Druskat & Others, 2006, P 152 to 189). Social awareness and relationship management on the other hand allow them to engage positively with their clients as well as with other participants in the social care structure (Druskat & Others, 2006, P 152 to 189). It is unfortunate that current research reports still underline the need for social workers to have more empathy for their clients.

“They found that ‘being listened to and understood’ was crucial for the carers. ‘Staff who took time to ask questions and hear complex and long stories of how the family were coping was seen as the most helpful’. These findings confirm previous ones and it is of great concern that people using services are still identifying that only some social workers are proficient in such crucial and basic skills.” (Sedan, 2005, P 7)

It is being constantly proved that the difference between the better social workers and the others can be narrowed down to skills like listening, non-critical acceptance, avoidance of moralistic or judgemental attitudes and other competencies directly related to EI.

New social workers need to heed such findings and focus strongly on improving their EI and E skills.

5. Conclusions

The principles of EI, when they were first elaborated by Mayor and Salovey raised significant interest in a world that was becoming increasingly competitive and insensitive; the possibility of people being able to adopt techniques and behaviours to work with greater cooperation, harmony and productivity was welcomed with enthusiasm. The path breaking work on the subject by Goleman in following years and the adoption of the tenets of EI in various areas of human endeavour, more noticeably in social work and in the HR functions of business firms, have resulted in its increasing popularity and application.

As is evident, EI can be applied in numerous areas by social work practitioners; it is an extremely useful skill and can be used productively in counselling, conflict management and various other areas of social work practice. Whilst interest in the area of human needs and actualisation has increased since the publication of Maslow’s theories, the evolution of specific theory on the issue has added a new dimension to the area by developing methods for people to increase their E skills and improve the quality and productivity of their working and personal lives.

Recent entrants to social work however need to realise that E skills and EI can increase only with constant inculcation and application of its principles and bare knowledge of theoretical tenets will not suffice in improving their EI competencies. With the tools and methods of improving EI still in the primary stages development, much more needs to be done to popularise the issue and encourage its application in various areas of social work.

The Boston EI questionnaire provides a good method of assessing personal EI, which is in consonance with the Five Step Method for improvement of emotional quotient (Druskat & Others, 2006, P 225). Younger social workers would be well advised to sincerely take the test and constantly improve their EI.

“Social services are nothing if they are not about empowering the powerless: giving older people the chance to stay in their own home, protecting the vulnerable from abuse and neglect, promoting independence and self reliance, bringing hope to families where almost all hope has gone”

Introduction

This report will assess to what extent social policy with regard to the elderly has been successful in achieving its aim. In doing this the paper will look at policy development from the late 1940s onwards. It will evaluate policy success and will look at the role of social work in particular. It will look at the impact of New Right thinking on social work policy, funding and practice. There will be an examination of the effect of social policy on vulnerable and oppressed groups and of how ageism and classism may contribute to oppression.

Methodology

This is a documentary report using internet sources for Government websites and official data which is supplemented by other literature. There will be some use of figures and a diagram to illustrate certain points. After looking at policy development the findings will be used to assess the impact of policy and its effects on vulnerable adults.

Policy Development

The introduction of the Britain’s post-war welfare state was aimed at combating disease, poverty and ignorance. It was designed to support people in times of trouble and to protect those who were unable to protect themselves. From 1948 onwards, what were known as the personal social services, was introduced, it consisted of the health services which were responsible for public health, and welfare departments which were responsible for residential care and the care of the elderly and disabled. It also included children’s departments which were responsible for child care.^[1] A large proportion of the budget was allocated for residential care.

Since its inception the way in which the welfare state has been administered has undergone two major reforms. The first of these was in the 1960s and 70s where allocation of funding to departments was transferred from central government to the treasury.^[2] In the 1960s welfare departments and children’s departments were unified into social services departments.^[3]The second phase was in the 1980s and 90s and it led to a restructuring of the public sector and the way in which welfare was administered. This led to:

The break up of administration into agencies, e.g. NHS Trusts and agencies responsible for Social Security.
The introduction of the principles of management and the market which are found throughout the NHS and personal social services
The requirement for public services to be run like markets, a separation of purchasing and provision of services and the introduction of competition.^[4]

During the setting up of the Welfare State the powers that had been held by local authorities were largely usurped by central government which still has the final say in how they conduct their affairs. Much of the work of the Social Services Departments was concerned with child services but this changed with the introduction of the NHS and Community Care Act of 1990 and there is a continuing move to operate services jointly. This also meant that care was no longer the preserve of the state, rather it should be the responsibility of the whole community. and state intervention should only occur as a final resort (Giddens, 2001).^[5] The Community Care Act of 1990 was a development not only of the 1948 Act but also of the 1970 Social Services Act which states that:

Every local authority shall establish a social services committee, and …there shall stand referred to that committee all matters relating to the discharge by the authority of- (a) their functions under the enactments specified in the first column of Schedule 1 to this Act^[6]

Under the terms of the 1990 Act everyone who wishes to access social care must first undertake an assessment of need (circular LAC (92) 12 states that any needs assessment needs to take into account the capacity of the person, their current living situation, any help or support from friends and relatives and also what the person themselves may want from care. The National Services Framework for Older People which is being continually updated has to be taken into account when such an assessment has been made.^[7] Undergoing an assessment does not necessarily mean that a person will be offered services. Different local authorities have their own sets of eligibility criteria, against which the needs of the person are assessed an assessment is also made of their ability to pay for care (Moore, 2002).^[8] The Health and Social Care Act 2001 entitled older people in residential care to free nursing care, in an attempt to integrate health and social care for older people. There has been concern that this Act might be the beginning of the end of adult social service departments.^[9]

Goodman (2005) has argued that access to care for older people may vary. The research suggested that those who were in residential care were more likely to be at a disadvantage in accessing other forms of care whereas older people who remained in their own homes were more likely to be able to access social care. The care needs of those older people in residential care tended to be met by care staff with the help of district nurses in order to provide some care to people in residential homes.

Assessment of Findings

Under the terms of the 1948 Act the state was the primary instrument of welfare and thus social care. As has been documented various later policies changed the way in which social care was distributed and accessed culminating in the Community Care Act of 1990 which shifted responsibility of care from central government to local authorities. It was claimed that this Act would lead to increased choices for service users. In contrast to this claim, some older, perhaps frail people, become socially disenfranchised and are placed in accommodation that is not up to standard nor suited to their needs. Moore (2002) points out that some commentators have argued that a mixed economy of care and the move away from public provision to one that was based on profit making:

…would actually lower the standards of care, as profit rather than public service becomes the overriding motive…(this) will lead to a narrowing of choice…clients being seen as receiving charity…(and) the extent and the quality of services will differ from place to place (Moore, 2002:259).

In 2000 the Government introduced the Care Standards Act as a response to poor standards in care homes. This has not been seen to be effective however, as stories of the abuse of older people in care have proliferated in recent years(Observer, 18^th February, 2001). In the last hundred years people’s life expectancy in the western world has increased dramatically and there are now almost 5 million people over the age of 75 in the UK. Conversely the birth rate is now at an all time low. These changes in British demographics have generated an increased demand on the health service and on caring services generally. Although many older people remain in their own homes and may receive some kind of care to help them, there are presently about 200,000 people in registered residential homes in England. 35,000 of these homes are run by the local authority and 165,000 live in homes run by the independent sector. These figures do not include the 150,000 old people who are in nursing homes (Moore, 2002).^[10] Older people are a marginalised group viewed by society as no longer useful, they are, of necessity, greater consumers of health and other services (Moore, 2002)^[11]. When they feel they can no longer cope alone, or when relatives can no longer care for them, they go into residential or nursing homes, many of which are privately owned and run for a profit. Even when they are in council run homes older people are expected to at least make a contribution to the cost of their care. What is principally needed is a change in the way older people access services. In order for older people to have their needs met in ways which contribute to their quality of life and give them some choice over what happens to them Dunning (2005) suggests a greater need for advocates. He argues that in certain areas advocates should be a requirement for older people at certain times in their lives such as:

retirement, which can bring about a reduction of income and social networks
a decline in physical and mental health, sensory impairment and the need for health and social services
a change in housing and living arrangements
ageism. ( Dunning, 2005:10).^[12]

Dunning’s advice is wise if people want to access adequate care particularly as under the terms of the 1990 Act the care is no longer provided by the state alone. If a service user has been assessed as eligible for care then what is called a care package has to drawn up by the social worker. This package is organized primarily by the local authority and voluntary and charitable organizations also play a part in this. Increasingly this has meant that the autonomy of the social worker in this process is rapidly being eroded they are not always able to do what they see fit with regard to a service user’s need due to the need to collaborate with other agencies.

Wanless (2006) found that access to care often depends on financial concerns and keeping people in care costs a lot of money. This has to be a consideration when the number of people entering residential care is increasing rapidly and estimated to increase by 50% over the next twenty years. The diagram below shows the cost of social care for older people in 2003/4.^[13]

Social worker’s decisions are subject to review by the care manager who is the person who holds the budget, this person’s primary job is to keep costs down. The social worker may do their utmost to obtain the best possible care for the older person they are dealing with but the final decision is often taken with regard to financial concerns. This is probably more of a problem with older people accessing care than with anyone else because they place a greater demand on the health and caring services.^[14]

When the welfare state was formed the total cost of residential care, or care that enabled a person to remain in their own home was met by the state. Those who went into private care did so as a matter of choice rather than a concern for the Government’s coffers. The New Right policies of Margaret Thatcher’s government was to roll back the welfare state and although the present government call their policies the third way they are very close to those of the New Right. Wanless (2006)^[15] maintains that there has been fragmentation in the responsibility for social care at both local and central government levels. After the 1990 Act local authorities were no longer the direct providers of care, rather they were care managers. As a result of this a large part of government funded residential care and 69% of domiciliary services are provided by the independent sector. Social care is managed like other businesses whereby those with the most acceptable tender will get the work. Is this an empowering experience for older people, or do they become more oppressed and discriminated against than might previously have been the case? The Government has tried to address some of these issues by its promotion of participation and service user involvement. This is not always helpful as Dunning (2005) has pointed out. This is because of the power imbalance that exists between service users and professionals. Professionals may also use language that is not always accessible to service users. Arguably, in the current climate, it helps older people to have an advocate who is there to offer support and to help promote their interests.

The Government pledged, in 201, that an older people’s champion would be appointed in each local authority. The champions would be there to represent older people’s interests. It was anticipated that as the champions should be doctors, nurses, other health professionals or social work practitioners, this might help to drive up standards of care. Quinn et al (2003) have argued that knowing what is on offer, and that if necessary there is someone who will put forward their views can be empowering for older people:

Information, advice and advocacy are services in their own right. They are also fundamental in enabling older people to receive the services they require. (Quinn et al., 2003, p. 3)^[16]

Conclusion

While the promotion of advocacy and service user participation may make accessing care easier for older people, and could involve greater levels of empowerment overall policy development appears to have placed financial concerns before the needs of vulnerable people. New Right policies have, to a large extent, been continued under New Labour. Most of the developments since 1970 have hedged social work practice so that professionals are limited in the types and amount of care that they can offer service users. They have introduced market principles into a profession that was built on a concern for justice irrespective of a person’s ability to pay. As a result I would say that policy does not fulfil its aims to bring hope to the hopeless and protect the vulnerable.

Bibliography

Dunning, A. 2005 Information, Advice and Advocacy for Older People York, Joseph Rowntree Foundation

Giddens, A. 2001 Sociology Cambridge, Polity Press

Moore, S 2002 Social Welfare Alive Cheltenham, Nelson Thorne

Quinn, A., Snowling, A. and Denicolo, P. (2003) Older People’s Perspectives: Devising Information, Advice and Advocacy Services. York: Joseph

Wanless 2006 Securing Good Care for Older People: Taking a long term view London, Kings Fund Publications

http://www2.rgu.ac.uk/publicpolicy/introduction/pss.htm#UK accessed 11/6/06

http://www2.rgu.ac.uk/publicpolicy/introduction/uk.htm accessed 11/6/06 ibid

http://www.dh.gov.uk/assetRoot/04/13/39/91/04133991.pdf accessed June 12th 2006

http://www.after16.org.uk/pages/law5.html accessed 12/6/06

1

A proposal of change to improve the quality of care for vulnerable older people who after being admitted into hospital and on discharge do not have a lot of choice in services that they receive. They are either sent home with a care package which does not meet all needs of the older person or moved to a residential home.

It has been said that independence and mobility are the two most precious commodities that the elderly, as a group, need to nurture as a significant decline in either will significantly increase their dependence and reliance on others, either in the family or in the community. (Whitely, S. et al 1996)

In general terms, the plight of the elderly in hospital is probably the most precarious of all of the age ranges, irrespective of the illness for which they were admitted. Any form of debilitating pathology, even if it only puts them in bed for a few days, may very well weaken their already tenuous grip on independence. The result may be either a prolonged stay in a hospital bed, home discharge with a care package which may not be totally satisfactory and all too often dependent on the ministrations of a group of overstretched healthcare professionals, or discharge to some form of residential care – which, although possibly seen by some as being the best option for the debilitated or infirm elderly, has an enormous impact on both the independence and the lifestyle of the elderly person.

Let us briefly consider this last option which is not as straight forward an option as may appear at first sight. Let us personalise the discussion by referring to a hypothetically representative Mrs J., a 78 yr. old lady who has lived alone since her husband died some ten years previously. She is fiercely independent but has been getting progressively more frail as the years have gone by to the extent that it is a struggle to get her shopping. As a result her diet is becoming progressively more inadequate.

Her personal hygiene, which was meticulous a few years ago, is now also failing, and she spends a great deal of her time alone and in bed. She has developed a low grade chest infection which required her to spend three days in hospital. When it came time to discharge her, her daughter could not look after her and took the decision that she would be better in a residential home. Mrs.J. had virtually no choice in the matter and on the fourth day she found herself in a residential home, surrounded by people with an average age rather greater than hers, many of whom were suffering from varying degrees of dementia.

The home had a completely imposed and inflexible regime which was a major imposition on her as she had previously been able to do what she wanted when she wanted. There was virtually no privacy and never a time, day or night, when there was silence or quiet. Her house had to be sold to pay the fees, so she knew that there was no possibility that she would ever go home again and any money that she had, she was not able to spend as her savings were also taken to pay the fees. In the space of four days her life had been overturned and although she was warm, fed and cared for, by any rationalisation her quality of life had changed for ever.

Mrs.J. is quoted as being fairly typical of many and her case used to illustrate the enormity of the life changing impact of admission to a residential home.

Critically examination the need for the proposed change

The particular change that we shall highlight in this particular essay is the need for multidisciplinary discharge planning, a move which is highlighted in the National Service Framework for the elderly (Standard Two).

As we shall discuss later in this essay, the National Service Frameworks have been conceived and drafted in response to the perceived need for change. It therefore follows that it is a self-serving argument that it is a recognition of a need for change in this area that has prompted its inclusion in the National Service Framework .This rather tautological argument is given credence by a number of studies that have both looked at, and demonstrated the need for change in this area.

The paper by Richards (et al 1998) was a first rate examination of the problem. It covered a number of areas, but, with specific relevance to our considerations here it highlighted how the patient outcome could be improved by a timely multidisciplinary pre-discharge assessment by a team which included social workers.

This paper, if nothing else, underlines the need for change and provides a model for how improvements in the multidisciplinary discharge function can produce potential benefits for patients

Evidence to support this view can be found in anyone of a number of recently published papers (such as Ham C 2004) which has specifically surveyed patient and carer satisfaction levels in the area of welfare and associated services after hospital discharge for the elderly.

An outline and critical discussion of how change can be implemented

Change can be a trophic factor in any organisation but no matter how good the intentions and aspirations, if it is badly managed, then the end result can be a catastrophic mess. One only has to consider the debacle of the implementation of the Griffiths Report (Griffiths Report 1983) in the NHS in the 80s to appreciate how a major management change could be badly implemented. The Government even set up its own commission to see what lessons could be learned from the episode. (Davidmann 1988)

If we consider the overall implications of the report in terms of change management, the innovations failed because they were imposed rather than managed. (Davidmann 1988)

Another fundamental concept in the field of change management is expressed by Marinker (1997) who points to the rather subtle difference between compliance and concordance. He suggests that human beings generally respond better to suggestion, reason and coercion rather than direct imposition of arbitrary change.

The management of change is perhaps the most critical of the elements in this discussion. There is little point in having vision or ideas if you cannot successfully implement them into reality (Bennis et al 1999).

The whole study of the Management of Change is built upon a set of constructs known as the General Systems Theory (GST). (Newell et al 1992). The process is both general and adaptable and can be summarised in the phrase “Unfreezing, Changing and Refreezing” or in simple terms, assessing a situation changing it, and then making the changes stick. (Thompson 1992).

All changes, but particularly health and welfare related ones, should only really be made after careful consideration of the evidence base underpinning that change (Berwick D 2005). In specific terms one should evaluate the need for implementation of a multidisciplinary discharge procedure by considering the evidence that the current situation could be improved, make managers aware of the findings of need and than be proactive in encouragement in terms of support of any decisions that are made to implement such moves.

The Political context

If one considers the pre-2000 structure and organisation of the NHS, one could come to the conclusion that there were three major problems which, some observers stated were not consistent with what was required of a 21^st century care provider, namely:

a lack of national standards
old-fashioned demarcations between staff and barriers between services
a lack of clear incentives and levers to improve performance

over-centralisation and disempowered patients. (Nickols 2004)

There have been a number of reforms in the NHS which potentially impinge on the cases of the dependent elderly. Arguably the most important was the NHS Plan (DOH 2000). This is a lengthy document which calls for some fundamental changes in the working practices, and in some cases the actual roles of a number of healthcare professionals.

An analytical assessment would have to conclude that, although there is a lot of detail in some areas of the plan, there is actually comparatively little detail in just how these changes should be actioned and arguably even less detail in what it expected the changes to be (Krogstad et al 2002). In the context of our discussion here, we should also note the natural ideological successor to the NHS Plan, was the Agenda for Change (2004). The National Service Frameworks were then introduced after seminal guidance from the National Institute for Clinical Excellence (NICE 2004)

The other reforms that have a bearing on our considerations are Choosing Health: making healthier choices easier (2004) and Building on the Best (2003). Both of these have considerable implications for the care of the elderly. The Choosing Health paper outlines the Government proposals for giving patients greater choice in the implementation of their health care and Building on the Best examines ways of improving and modifying current practices. There are specific references to the discharge procedures which are relevant to our discussions here.

The Health context

In the context of this essay the NHS Plan called for a number of reforms including:

Increase funding and reform
Aim to redress geographical inequalities,
Improve service standards,
Extend patient choice.

Each of these areas has a bearing our Mrs.J. The geographical inequalities were primarily due to the historical context in which each area had implemented their own services together with the balance between funding and demand in each area. The improvement in service standards is mainly driven by the National Service Frameworks and he extension of patient choice clearly has a bearing on Mrs.J. although the choices available may well be less in practical terms than the complete spectrum of what is actually available and may well be constrained by factors such as available funding and the patient’s own physical state. (Wierzbicki et al 2001)

The National Service Frameworks (amongst other things) sets out to reduce inequalities in service provision between providers and also to set standards of excellence, together with goals and targets that are nationally based rather than locality based. (Rouse et al 2001).

National Service Framework Standard Two has as its stated aim to:

Ensure that older people are treated as individuals and that they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries.

It is formulated within the concept of “Person Centred Care”. This is intended to allow the elderly (and their carers) to feel entitled to be treated as individuals, and to allow them to be responsible for their own choices about their own care.

The Social Care context

If we accept that a patient’s discharge from hospital is dependent on many disparate and variable factors including (apart from their obvious health considerations), for example, their financial, dependence and support network status. It therefore follows that before a considered decision can be made to discharge the patient, a full and careful assessment of these various aspects should ideally be made. (Gould et al. 1995). The input of the social worker to the multidisciplinary pre-discharge team is therefore vital in this respect as it is unlikely that other healthcare professionals will be in a position to make an assessment of all of these factors.

If one reads contemporary peer reviewed literature on the subject, the term “seamless interface” is a concept that frequently appears. (Dixon et al 2003). This reflects the moves towards the dismantling of the “Empire” concept of each health and welfare related subspecialty. (Lee et al 2004). And the positive integration of each, for the overall benefit of the patient.

Central to this process is the advent of the Single Assessment Process (SAP) which is arguably the most important new work practice to facilitate good multidisciplinary working practices. This reduces the duplication of work, derivation of facts and paperwork that hitherto was commonplace (Fatchett A. 1998).

In specific consideration of our Mrs.J. we could find that she was visited by one member of the discharge team (typically the social worker), and an assessment of all of the factors that we have discussed could be made and recorded in a single central document or reference point (computer). It is the stated aim of the SAP that the needs and wishes of the elderly patient will remain at the heart of the whole process. (Mannion R et al 2005)

To consider the requirements of the National Service Frameworks and in the context of social work we should also mention the concept of the carer’s or patient’s “Champion” that has been specifically encouraged. (Bartley M. 2004). These are designated workers (often specially trained or experienced social workers), who would stand up for the need of the patient or their carers. In Mrs.J.’s case we could postulate that such a champion could assess her needs as being more appropriately dealt with by an intensive course of both physiotherapy and an occupational therapy input rather than necessarily being arbitrarily placed in a residential home.

The social worker is ideally placed to assess and indeed to action interventions such as that of the occupational therapist, who can be shown to produce considerable impact on the ability of the infirm elderly to remain at home. (Gilbertson et al 2000). We should not leave this area without a demonstration that the evidence base in this area of social worker input as being both positive and beneficial by quoting the Logan paper (et al 1997)

References

Agenda for Change, 23 November 2004, Government White Paper: HMSO 2004

Bartley M. (2004), Health Inequality. An Introduction to Theories, Concepts and Methods. Cambridge: University Press 2004

Bennis, Benne & Chin (Eds.) 1999, The Planning of Change (2nd Edition)..

Holt, Rinehart and Winston, New York: 1999.

Berwick D 2005 Broadening the view of evidence-based medicine Qual. Saf. Health Care, Oct 2005; 14: 315 – 316.

Building on the best 2003, Department of Health: HMSO: London 09/12/2003

Choosing Health: making healthier choices easier 2004

Government White Paper, HMSO: London 16.11.2004

Davidmann 1988, Reorganising the National Health Service: An Evaluation of the Griffiths Report, HMSO : London 1988

Dixon, Holland, and Mays 2003 Primary care: core values Developing primary care: gatekeeping, commissioning, and managed care BMJ, Jul 2003; 317: 125 – 128.

DOH 2000, NHS Plan, HMSO; London 2000

Fatchett A. (1998), Nursing in the new NHS: Modern, Dependable. London: Bailliere Tindall

Gilbertson, Peter Langhorne, Andrew Walker, Ann Allen, and Gordon D Murray 2000 Domiciliary occupational therapy for patients with stroke discharged from hospital: randomised controlled trial BMJ, Mar 2000; 320: 603 – 606 ; doi:10.1136/bmj.320.7235.603

Gould MM, Iliffe S. 1995, Hospital at home: a case study in service development. Br J Health Care Manage 1995; 1: 809-812.

Griffiths Report 1983

NHS Management Inquiry Report DHSS, 1983 Oct 25

Ham C. (2004), Health Policy in Britain [5th ed.] Basingstoke: Palgrave Macmillan

Krogstad, Dag Hofoss, and Per Hjortdahl 2002 Continuity of hospital care: beyond the question of personal contact BMJ, Jan 2002; 324: 36 – 38.

Lee, Wong, Yeung Wong, and Tsang 2004 Interfacing between primary and secondary care is needed BMJ, Aug 2004; 329: 403.

Logan PA, Gladman JRF, Lincoln NB. 1997, A randomised controlled trial of enhanced social service occupational therapy for stroke patients. Clin Rehab 1997; 11: 107-113

Mannion R, Davies H, Marshall M (2005)

Cultures for Performance in Health Care. Maidenhead: Open University Press

Marinker M.1997, From compliance to concordance: achieving shared goals, BMJ 1997;314:747–8.

Newell & Simon. 1992, Human Problem Solving. Prentice-Hall, Englewood Cliffs: 1992.

NICE 2004, Management guidelines : NHS Directive; HMSO, Tuesday 7 December 2004

Nickols F 2004, Change Management 101: A Primer, London : Macmillian 2004

Richards, Joanna Coast, David J Gunnell, Tim J Peters, John Pounsford, and Mary-Anne Darlow 1998 Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care BMJ, Jun 1998; 316: 1796 – 1801

Rouse, Jolley, and Read 2001 National service frameworks BMJ, Dec 2001; 323: 1429.

Thompson 1992, Organisations in Action. McGraw-Hill, New York: 1992.

Whitely,S. et al (1996) Health and Social Care Management, Basingstoke: Macmillan.

Wierzbicki and Reynolds 2001 National service framework’s financial implications are huge BMJ, Sep 2001; 321: 705.

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PDG

A COMPARATIVE STUDY OF ELDERLY CARE AMONG HINDUS AND MUSLIMS IN RURAL AND URBAN AREAS OF ALIGARH DISTRICT

A comparative study of elderly care among major religious community of Aligarh district

Introduction:

Since time immemorial, across the world history, care affairs of the elderly were totally family concerns, carried out mostly at home by women and elder themselves (Bookman & Kimbrel, 2011). In the twenty first century the needs, rights, concerns and problems of elderly persons are getting more attention of people from different walks of life i.e. social scientists, statesmen, administrators and social workers etc. Aging is neither a new phenomena nor a kind of ailment rather it’s a latter part of life cycle, considered one among the most challenging phenomena around the world- irrespective of developed and developing country as well. In, India, family based care of elderly is fastest growing concern for the big chunk of elderly population, about hundred million.

This study seeks to highlight the existing pattern of care affairs of elderly in the informal setting, and interaction between elders and cares in the family. Here, more emphasis has given to peep into the nuts & bolts of care relations among elderly and their family members.

Research problems

In the last couple of decades, innovation of wide range life saving drug, its availability and accessibility to common man have improved health of elderly, consequently the raised the life span of people worldwide and in India too, in contrast to previous normal age. That demanding lot of care and support for them includes medical, financial, psycho-social, spiritual and religious care. Now India is the home of about100 million people, taking care of elderly is of course a serious affair, can’t be left as it is going on. In due course of time, by the introduction of industrialization, urbanization and modernization in India, living style has drastically changed, where institution of joint family transformed into nuclear family. The industrial revolution not just change the people living standers, rather it’s too altered the age stratification resulting, lessen the power, prestige and importance of elderly people in society, finally, the elderly turn into social elite to social problems (macionics,2013). Because, the paradox, whether the responsibility of elderly care is a family matter or of government, becoming a matter of concern in India.

Literature review
Significance of study

From the prehistoric time, India has been a country of care, love, affection, companionship and intimacy, where elder’s status remained matter of high consideration and elders considered as nucleus of power. Till the pre-independence era, most of the families were living jointly and agriculture was the major source of income and elders were the headed the family. But, after the industrialization, urbanization and modernization, joint family turned into nuclear family. Now, their position is no more, some time their status worst to social problems. Elderly people above the age of 60, have less resources, income and high life expectancies, require more, need, concerns and cares.

Objectives of the study
To undertake a socio-economic, and situational analysis of the condition of the elderly people in the family.
To comprehend the pattern of family based elderly care practices in terms of various parameters such as religion, area (Rural-Urban), class and gender etc.
To develop an extensive list of needs and difficulties as faced by elders in the family.
To decipher psycho-social and emotional conditions of elderly people and associates factors.
To identify the influence of religion and religiosity on care of elderly.
To critically assess the changing value systems and social institutions that impinges upon the care and social support system with reference to the elderly.
To study the level of awareness among the elderly as regards policies, programmes and legislatives provisions & safeguards in India.

Key Words: elderly, elderly care, family based care practice, religion and religiosity

Conceptual framework
Research questions

This study will focus on the comparison care concerns and status of elderly care in the family among Hindus and Muslims in different settings i.e. rural and urban area. Further will seek to answer the following important questions concerning family based Elderly Care.

What are the existing system and patterns of elderly care in the family?
What are the dimensions and the level of care provided by the family members?
Who is the responsible person for the care of elderly in the family?
What is the quality of the elderly care in the family settings?
What are the major day to day challenges of elderly care in the family?
What is the impact of structural changes in the family on elderly care?
What are the sources of livelihood of elderly people?
What is the attitude of elders toward the care provided by family members?
What is the level of satisfaction among elderly about their care?
What are the role of religion and religiosity on care relation and care of elderly in the family?
What are the differences and similarities in the family based elderly care among Hindus and Muslims in rural areas.
Research Methodology
Scope of the study

This study will focus to study the day to day pattern of care relation and care of elderly and most possible issues and challenges, encountering elderly people within the family. This study will explore the level of differences and similarities of elderly care, among Hindus and Muslims family on the one hand and rural and urban on the other hand.

Universe and Sample

The study will be conducted in the selected rural and urban areas of Utter Pradesh, particularly in Aligarh District. The basic respondent of the study will be elderly people (60 or more age) and their potential caregiver in the family.

Sampling Frame

First of all, willing elderly people for being respondent for the purpose of study will be enlisted, respective to their economic classes, religion and sex, would be helpful to have proper result of the study.

Sampling Method & Sample Design

As elderly care is personal and sensitive issue the sample would be selected on the basis of purposive sampling stratification of the universe will be on the basis of religion (Hindu & Muslim), areas (rural & urban) economic class (upper, middle and lower), and sex.

SAMPLE DESIGN

CLASS

Urban

Rural

GRAND

TOTAL

Muslims

TOTAL

Hindus

TOTAL

Muslims

TOTAL

Hindus

TOTAL

Male

Female

Male

Female

Male

Female

Male

Female

UPPER

10

10

20

10

10

20

10

10

20

10

10

20

80

MIDDLE

10

10

20

10

10

20

10

10

20

10

10

20

80

LOWER

10

10

20

10

10

20

10

10

20

10

10

20

80

Total

30

30

60

30

30

60

30

30

60

30

30

60

240

Tools and techniques for the data collection

This study would be based on qualitative as well as quantitative data. Therefore mixed approach will be adopted, includes survey research for quantitative data to have empirical analysis and qualitative methods i.e. interview schedule and case study method will be used to comprehend a comprehensive and wider description to fill the gap of quantitative data. Through, direct observation and in-depth interview of elders, issues and concerns of their care in the family would be more elaborated and will cover all aspect of their care life, includes, their living arrangement, relationship with family members, in the family

References

Bookman, A. & Kimbrel, D. (2011) Families and elder care in the twenty-first century. Princeton University, 21 (2), 117-140.

Macionics, J.J. (2013) Social problems. New Jersey: Pearson publication.

Ageing is the universal phenomenon encountered by every human individual across the life span. All human beings expect for a healthy and happy old age but not many of them manage to get all those in reality. In this current century, world scenario is changing rapidly in the form of rise in elderly population than before. Many developing countries including Pakistan are affected by this global change. A report on global health and ageing shared recent statistics that in 2010, an estimated 524 million were aged 65 years or older making 8% of world population. It is interesting to note that by 2050 this number is expected to triple to about 1.5 billion signifying 16% of world’s population (WHO Report, 2011). Ironically, in developing countries, geriatric population between 2010 and 2050 is expected to increase more than 250 percent as compared to developed countries. Ali and Kaini (2003) add that this trend in ageing is the result of the demographic shift in fertility rates in combination with mortality rates resulting in ageing of the population (p. 1). Having a glance at our national scenario, it is estimated that the proportion of population 60 years and above in Pakistan will increase from 5.8 percent in the year 2000 to 7.3 percent in 2025 and 12.4 percent in 2050 (United Nations, 2002).

Reason for the selection of this topic

I came up with my thesis topic as every year particularly on festivals such as Eid, different media channels broadcast programs where views of elderly who are residing in their shelter homes are taken. The eye catching moment was the pain and cry these ageing parents expressed, when their children neglected and dumped them in shelter homes, when they most need support in their last years of life. This event influenced me to work for my thesis in the field of geriatrics. Therefore, in the light of the significant global and national figures, the anticipated demographic trend will result in more ageing population. Increase in ageing will predispose the elders to suffer in chronic illnesses, disabilities and new disease patterns. Another, considerable growing fact is that, due to the shift of societal paradigm, elderly population will be the most vulnerable group requiring health attention currently and in the years ahead. Therefore, it is recommended that older adults should remain socially active in their later years (Bergstrom, Holmes & Pecchioni, 2000). The findings from the proposed research contribution in this area particularly in Pakistani context will assist in filling the gap where elderly population can regenerate themselves without being isolated from social life, and can live with quality, dignity and free of violence in their empty nest days.

Significance of the problem

Many decades ago the concept of violence against women and children was objected throughout the world but researches in these areas have resulted in the protection and formation of laws for these groups. Likewise, elderly abuse is yet another novel and critical public health and social issue that need prompt attention. Infact, it is one of the most serious subject which is under reported nationally and internationally resulting in thousands of silent victims. Numerous studies are being conducted in the developed countries on the various aspects of the ageing population in order to ensure optimum quality in the later phase of life time. However, many of the South Asian countries including Pakistan are facing serious challenges of decreased economy, low savings, high inflation rates; financial benefits for few percentages of government employees, lack of health insurance coverage are making the life of this vulnerable group questionable. Apart from these encounters, elderly population are confronting with the decline of extended family system and the emergence of nuclear families (Jalal & Younis, 2012). In Asian cultures, many of socio cultural practices are grounded on concept of extended family system. Old members of the family are taken care by the young generation and it is regarded dishonorable if any elder lives alone or in nursing home. In addition to it, this transition has led to the decline in elder decision making power and position and to enjoy later years with dignity and self-worth. Due to this conversion “the elderly are at risk, as the younger and more productive members of the family take over, marginalizing the elderly into positions of dependence both social and economic”(Subzwari & Azhar, 2010, p. 2).

Another important change that has taken place in the last couple of years is that younger individuals are migrating for better employment opportunities leaving behind parents with no one to care for them, causing elderly to live alone or they are shifted to shelter homes. Sabzwari and Azhar (2010) supports that “one in five patients at the tertiary care hospital in Karachi are elderly. It is estimated that at least 6-7 % of elderly visiting geriatric clinics at the Aga Khan University Hospital Karachi are living alone with little assistance” (p. 2). Increase in life expectancy has led to substantial increase in aging population globally and it is predicted that “the world’s elderly population will continue to increase with an estimated rate at 67 % residing in developing countries by the year 2020” (Karunakara & Stevenson, 2012, Ageing population section, para. 1). In Pakistani context, 60 years is designated as the age of elderly. Jalal and Younis (2012) shares WHO report that:

5.6 % of Pakistan’s population was over 60 years of age, with a probability of doubling to 11 % by the year 2025. Pakistan’s life expectancy was increased from 45.6 years in 1950 to 66.8 years in 2008 with a probability of increasing to 72 years by 2023 (p. 2).

Hence, the decline of popular extended family system and rise of career oriented families, and change in familial values compounded by substantial increase in ageing, subjects older population to maltreatment and this area requires immediate consideration. Jamuna (2003) rationalizes that “a series of developments, such as urbanization, industrialization, and migration, and a growing sense of materialism and individualistic orientations have threatened the culture of yesteryear (p.129). One significant cause for low rate of abuse in Asian cultures is compliance to the value of respect for their elders whereas western cultures sideline them but alarming sign is that this cancer is gradually growing in our culture.

Research question

Older people are left with countless problems in their later phase of life where these years are believed to live in respect, solemnity and self-worth with their married children and grandchildren. On the contrary, this age group has to spend their lives in isolation at home or in shelter homes due to neglect and cruel treatment by them. Although, these old homes are answer to most in need yet they still not provide a solution to majority of the population. Our culture despite its gradual transformation still adheres to the value of caring for their elderly at home (Subzwari & Azhar, 2010). Elder abuse is the alarming public health issue present in both developed and developing countries. Very little information is available regarding the extent of maltreatment in elderly especially in developing countries, it is estimated that 4-6% of elderly people have experienced some form of maltreatment at home. (WHO fact sheet, 2011). However, older people are often afraid to report cases of maltreatment to family, friends, or to the authorities. There is no reliable data or research conducted in Pakistani context, where sufferings of these elderly populations living in nursing homes could be researched and addressed. Dildar, Saeed and Sharjeela (2012) mentions that “elder abuse and neglect are difficult to quantify as these occur in the privacy of the home, institutions and under reported in our country” (p. 662). Based on the above facts and literature I came up with the research question that, what are the experience and the perception of elderly people living in nursing home in Karachi, Pakistan?

Literature search strategy

Literature search was conducted in a systematic way by utilizing available electronic databases, in order to review and explore existing literature related to abuse of elderly population in nursing home. In order to detect relevant literature, two major databases, CINHAL plus with full text and PUBMED was used. Another search engine like Google scholar was also searched to find the relevant literature sources. These databases were searched for the time period between the year 2000 and 2012. Different key words or combination of key words along with the use of Boolean operators were used for all search engines, like elder abuse and nursing homes, elder maltreatment and nursing homes. A synonym for elder abuse like geriatric abuse and for nursing home like shelter home was typed on the search bar. Relevant articles were hunted when the key words were written in research title, abstract of review articles of all data bases. A separate search was carried out for identifying the available literature in Pakistan for this purpose the term Pakistan was added along with other key words to search relevant Pakistani sources. Reference lists of retrieved articles from these databases were also checked for relevant literature. Search from all data bases were narrowed down by the use search filters like year range, gender, age and language. For detail literature search and number of hits (See appendix A).

Literature review analysis on elderly abuse in nursing homes
Definition

The subject of elder abuse began to receive recognition since 1970, and the first boom on elder abuse appeared in UK medical journals in 1975 as “granny battering”. It was identified by British Gerontologist and the first population based study was done in USA in 1988.

International Network for the Prevention of Elder Abuse (INPEA) defines “elder abuse is 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” (INPEA, 2002, p. 3). Age bracket for elderly is 60 years and above. Some predictions indicate that one million people turn 60 every month and 80 % of these are from the developing world (WHO/INPEA, 2002). All the susceptible victims of abuse who are 65 years or more and suffering from mental disorder, chronic disease, and disability largely depend on the funded institutions or NGO’s but if there is financial constraint then these vulnerable groups have to confine them to home. (srilanka 2009).

There is considerable debate on the definition of elder abuse because some cultures foster certain behaviors that may be considered as abuse in different cultural context. In Australia, “elder” refers to older local people who have specific positions of power within native communities. It was recommended that “elder abuse” be replaced with “senior abuse” in an Australian context as it referred to original and senior population (Ryan, 2009). It can be argued that abuse occurs within a relationship where there is an expectation of trust, no matter different cultures gives different definitions on elder abuse. However McFerran (2009), asserts that “research on domestic violence in elderly women asserts that, it is based on unequal power relations and traditional devaluation of women, not on relationships based on trust” (as cited in Ryan, 2009, Definition of elder abuse, para. 3). Therefore, irrespective of the type of abuse, it will definitely result in pointless miseries, pains and sorrows, and decrease quality of life of elderly.

Types of elder abuse

Elder abuse is categorized into five different types: physical abuse, psychological /emotional abuse, financial/material abuse, sexual abuse and neglect (WHO/INPEA, 2002). Most recent data from USA states that, there are about 570,000 cases of elder abuse reported each year, 55% of the cases suffer from neglect which is the most common form of elder maltreatment (Facts on elder abuse, 2012). Economic abuse is one of the most frequently reported forms of abuse, followed by neglect, psychological or emotional and finally physical abuse. Sexual abuse of elders is not reported as frequently as any other type of abuse (Ryan, 2009).

Another dimension of elder maltreatment is that it is not restricted to home environment, risk is even leaving them in nursing homes, hospitals and long term care facilities. An empirical study in New Zealand reveals that psychological abuse (59%) is followed by material/financial (42%) and physical abuse (12%) were most frequently identified types of abuse. Sexual abuse occurred in 2% of reported cases (Gadit, 2009). Canada is one of the world’s highly civilized countries reports that 22% of Canadians think a senior they know personally might be experiencing some form of abuse, 90% feel that the abuse experienced by an older person often gets worse over time ( Govt of Canada,2008, quick facts on elder abuse in Canada ).

Implications of the proposed research in nursing

It is a challenging task for all health care providers to efficiently assess the elderly group so that abuse can be identified and reported for the immediate interventions. Proposed research on this subject will make people aware, that elder abuse will prevent older members from being favorable and positive members of the society. Furthermore, evidence based knowledge on this matter will assist in safeguarding and promoting welfare of the elderly clients. According to Lachs and Pillemer (1995) guidelines from the American Medical Association suggest that “all older adults be asked by their physicians about family violence, even in the absence of symptoms potentially attributable to abuse or neglect” (p. 438). A careful history taking and interviewing technique is crucial in identifying accurate information on the possible abuse. If the violence on elder is confirmed then priority is to ensure safety of the elderly person by separating from the perpetrator. In the western countries, based on their cultural background, majority of the old age population resides in shelter homes. In Karachi, nursing homes are managed by private NGO’s or religious organizations. The Catholic Church runs three old people homes in Karachi, and people residing in these old homes pay a minimal fees, and rest are generated through the church (Subzwari & Azhar, 2010). Some nursing homes are governed by religious communities functioning wihh the help of volunteer and donation support. Gadit (2009) identifies that “Edhi Foundation is one glaring example of a service where abandoned elderly people are housed. These elderly people are shunned away by their children under different pretexts like poverty, illness among elderly and general intolerance” (p. 3).

Recommendation for the prevention of elder abuse

A national policy for the promotion of better health of the elderly was designed in 1999, but implementation is yet to be seen. This policy integrated training of primary care doctors in geriatrics, availability of dental care, domiciliary care, and a multi-tiered system of health care providers for elderly including physical therapists and social workers. (sabeena jaleel 2012).

An important recommendation is the initiation of awareness programs among health care professionals on the subject and the formulation of assessment tools to detect abuse. Another, is the workshops for nursing and medical graduates should be conducted to detect and manage elder abuse more effectively resulting in prompt treatment measures. Potential research on various aspects of care of elderly can urge in the development of policy at governmental level for the protection of geriatric population1.

At national level, electronic and print media can play a key role in raising awareness on this subject. It can act as a medium for the provision of specially funded and recreational shelter homes, free health care facilities, and formation of legislative policies (Marshal, Benton & Barzier, 2000.

Research Methodology

The research approach which would best fix on the research question would be qualitative in nature. I would like to go for Phenomenological method as it deals with the truth about reality built in people’s lived experience (Polit & Beck, 2008, p. 227). This approach can be applicable on those concepts which are central to the life occurrences of the human being. The core goal is to completely understand persons lived experience and perceptions that it will generate.

Inclusion Criteria

Inclusion criteria will involve all elderly people with an age of 60 years and above in both the genders. Another would be all elderly population living in nursing homes in Karachi.

Exclusion Criteria

My exclusion criteria would be all elderly below 60 years of age.

Conclusion

Whenever a question arises, like what are the effects on children of alcohol dependent parents, we all have the option to put forward a few answers and to set this topic aside. “Alcoholism is also known as a family disease. Alcoholics may have young, teenage, or grown-up children; they have wives or husbands; they have brothers or sisters; they have parents or other relatives. An alcoholic can totally disrupt family life and cause harmful effects that can last a lifetime” (Tetyana Parsons, 2003). Life is something what we have to pass over moral values and good living examples to the next generations.

Since we all belong to family, we can never ignore the relevance of family life, and in family children are supposed to get the primary consideration and caring. But in an alcoholic’s family, the most affected group will be their children. “Parents who abuse alcohol could cause a negative impact on their children’s lives. Feelings of anger and neglect can follow a child throughout adulthood and have a detrimental effect on his relationships with others” (Bogle, D. 2010).

Dustin Bogle, an experienced fitness instructor, nutritionist and fitness article writer, gives some major problems that occur to alcoholic’s children. Aggressive behavior is one of the first characteristics that a child might develop from having a parent who abuses alcohol. The aggressive behavior of children may lead to academic failure and serious social problems.

As the second one, he mentions warning signs. Children may show warning signs of having an alcoholic parent. They may act out in anger with other children, or might find them lying about things. When scolded, children may become scared of their parents finding out, or they may be causing trouble because they want that extra attention that they are not receiving at home.

The environment that the children are placed in is often unpredictable and chaotic. This is the third point he puts forward. The oldest child in the group is taking care of the other children while the parenting skills are lacking. Other children may become trouble-makers, and some resort to isolation, often becoming shy and unresponsive to other children.

The last observation of Dustin Bogle, probably a crucial one, is the cycle of addiction. It is a very common and dangerous occurrence, and lot many dilemmas are attached with this as well. Criminal acts, teen pregnancy and other mental and emotional issues may arise. The children may become institutionalized in either jail or a rehabilitation center. Children may also be taken out of their home if the alcohol abuse becomes really bad, or they could be put in foster care or end up living on the streets.

Alcoholism is a widespread disease, and it has deep rooted health related issues and severe long lasting consequences. The funniest thing in regards with alcoholism is that still it is being considered as a medium of socialization. The behaviors of parents are the guidelines of their children, and it doesn’t matter whether it is good or bad. Amber Keefer, a famous health related article writer who has more than 25 years of experience in the field, is presenting some very good information in this particular matter. Fear, low self-esteem, self-blame, injury/illness, financial effects, and changes in Family Structure are the effects that she suggests for a review. If we can have a deeper look in to each point, we can see that all these points are very relevant.

Children of parents who abuse alcohol often live in fear, primarily because they are abused or neglected when a parent is under the influence of alcohol. They may witness domestic violence against the other parent, their siblings or even other adults living in the household. Children who are frightened for their own safety may suffer from anxiety, sleep disturbances and depression.

Children often develop low self-esteem when one or both parents abuse alcohol. When parents are more preoccupied with alcohol abuse than their parental roles, a child may not get the sense of security he needs to develop healthy self-esteem.

Children often blame themselves when a parent abuses alcohol. They think that it must somehow be their fault if a parent uses drugs or drinks too much alcohol, and that will result in the loss of their self-reliability.

Children can suffer injuries or health problems as a result of a parent’s alcohol abuse. If a pregnant woman drinks alcohol, the baby can develop long-term health problems. The unsanitary and unsafe situation at home may lead to certain type of illness and injuries.

A family with an alcohol abused parent will definitely have economic consequences, and that family will be forced to live a low income life. Such a situation may develop an inferiority complex in children.

Separations and divorces may happen in such families and those incidents will create even more stress and confusion for children. A child who is being raised in a single parent house hold, may not get proper care or even unable to get better developmental opportunities.

“Patti Kelly” a freelance writer and registered nurse with many years of experience in pediatrics, geriatrics, public health and preventive care have made some serious observations on this topic. She is describing the effects under certain specific classifications; they are: psychological, educational, economical, social and developmental.

Denial, anger, shame, anxiety, hopelessness, self-neglect, shame and isolation are a few of the psychological consequences noted in children of alcohol abused parents, and a sense of security and positive outlook are difficult to establish for such children.

Children of alcohol abused parents are at an increased risk of learning disabilities, poor school attendance, and they are also more likely to be expelled, be institutionalized or drop out of school.

An alcohol abused person is always in a risk of being either unemployed or under-employed and lack of income results in an overall decrease in the family’s standard of living and can lead to difficulty meeting basic needs.

The children of an alcoholic may be ashamed to go out in public, and such shame and fear may also prevent them from having friends over.

Trust and security are being considered as the promoting agents of promote healthy development and a family with alcohol abused parent can never provide such a situation at their home. Physical and sexual abuses are also more common when there is a parent who abuses alcohol, and these factors, may negatively impact a child’s normal development, making children more prone to suicide, anxiety, eating disorders and depression.

As a part of this research, it is very important to note about the treatment side of the alcoholism. As I mentioned earlier, alcoholism is a disease which requires specific treatment, even though there is no medical treatment for that. But alcoholism is a treatable disease and many treatment programs and approaches are available to support alcoholics. Motivation is the major portion in treatment of alcoholics, and other important step is the self-decision. We can categorize the treatment in different steps, they are, commit to stop drinking, set goals and prepare for change, withdrawing from alcohol, find new meaning in life, plan for triggers and cravings, get support and getting started on treatment. Although it is not that easy to achieve, a powerful will and support from others, the goal is so close.

The importance of this research is that what the role of a teacher in this issue is. Since the group I have taken into consideration here are children, and only because of that without any doubt I can say that a teacher can do wonders in this particular issue. Motivation is the better medicine for this and a teacher can do it very easily. Normally, almost all the parents are too much concerned about their children, and a teacher will get lots of opportunities to have detailed observation and discussion with parents. A teacher can include the topic “alcoholism” in their monthly meetings, and they can conduct one on one meeting with parents in which they can collect details of their family. The moral support for the children is the greatest part in this, and the teacher is the best ever person who can provide that.

All the above finding and studies are giving us a clear picture of the consequences that could happen to the children of alcohol abused parents. If we can have quick look, we can see that the alcoholic abuse of parents has strong influence in their children’s future. Psychological, educational, economical, social and developmental issues can be counted as the major problems of the children of alcohol abusing of parents. Even though there is no medication, treatment of alcoholics is very important. Since a teacher has an influential role in a child’s life, a teacher is supposed to pay more attention in giving moral support to children.

For me, preparation of this research paper was an exciting experience. I am sure that the pieces of information that I shared here is just like a drop of water from an ocean. Although I had a chance to do a survey in this subject before, I was quite ignorant about its consequences fully. Most of the information that I gained through this research is really worthy. If we can do a little bit more deep research, definitely there are a lot more issues that we can find. The importance of peer groups and communities in the treatment of an alcoholic is a relevant question that I would like to rise. As the alcoholism is a social disaster, what are the steps that could be taken by the official authorities, in order to have control on this, is the question that I would like to ask. As an ECE student what I can offer is my moral support to the children those who are having this issue, and my effort to educate the society in regards with this dangerous problem.