Category: Free Essays

This paper states the definition and main risk factors of drug abuse at first. Then, it reviews the three models for drug abuse prevention, including information model, affective model and social influence model. It also mentioned chemical treatments and psychological treatments of drug abuse. There are some comments on the psychological treatments. The author brings up some prevention and intervention plans of adolescents’ drug abuse in the last part.

Keywords: drug abuse, adolescents, prevention and intervention

Introduction

What is drug abuse? There are many definitions of it. Usually, common people think that taking drugs can satisfy persons’ desire of happiness. Just as Miller (1995) states “Drug abuse implies willful, improper use due to an underlying disorder or a quest for hedonistic or immoral pleasure” ??p. 10?‰. Actually, it includes many aspects – not only social values but also scientific view and not only physical reasons but also psychological elements. So the definition of drug abuse typically refers to 4 dimensions, including the nonmedical use of a substance, altering the mental state, a manner that is detrimental to the individual or the community and illegality (Abadinsky, 2001).

Papalia, Olds and Feldman (2009) define substance dependence as physical addiction or psychological addition or both to a harmful substance. If an adolescent has drug abuse, the abuse can lead to “substance dependence, or addiction, which may be physiological, psychological, or both and is likely to continue into adulthood” (Papalia et al., 2009, p. 366). Addictive drugs have particularly high risk for adolescents as they stimulate parts of the developing brains of adolescents (Chambers, Taylor & Potenza, 2003).

As economic developing, the drug-taking situation of adolescents is not getting better. According to the World Drug Report 2010 (United Nations Office on Drugs and Crime [UNODC], 2010), drug use has stabilized in the developed world, however, there are signs of an increase in drug use in developing countries and growing abuse of amphetamine-type stimulants and prescription drugs around the world. From 2004 to 2009, the number of drug-taking people who was under 21 years old was increased by more than 50% in Hong Kong (Zhu, 2010). What are the risk factors for drug abuse of adolescents? There are 4 kinds of common risk factors??including Psychosocial Factors ??Low Self-esteem, Depression and Suicide?‰, Family Factors (Low Familism, Family Substance Abuse Problems and Parent Smoking), Peer Factors (Perceived Peer Approval and Perceived Peer Use) and Deviance Factors (Disposition to Deviance and Delinquent Behavior) (Vega & Gil, 1998). It cannot easily say which factor is the most important one. It depends on the situations those different adolescent experiences.

Three Models for Drug Abuse Prevention

Drug abuse prevention aimed at reducing the supply or the demand for drugs of abuse (Abadinsky, 2001). There are three models (Ellickson, 1995) that focused on schools and school-based antidrug programs, including information model, affective model and social influence model.

Information Model

Adolescents can probably avoid drugs, if they comprehend their potential hazards, so this model mainly aimed at giving information. “The information model posits a causal sequence leading from knowledge (about drugs) to attitude change (negative) to behavior change (nonuse)” (Ellickson, 1995, p. 100). Sometimes the shock or scare is needed in this model, such as “hard hitting” antidrug videos, talks by ex-junkies, or TV and billboard campaigns that show the scared situation of drug use (Cohen, 1996). This model primarily focuses on the educational approach. It was supposed that students can make rational decisions to keep away from drugs because of increasing knowledge (Abadinsky, 2001). Through information model, adolescents can have a correct and renewed awareness of drug abuse.

Affective Model

This model pays more attention on individuals themselves and their personality. “The model assumes that adolescents who turn to drugs do so because of problems within themselves-low self-esteem or inadequate personal skills in communication and decision making” (Ellickson, 1995, p. 101). This model has an attempt at improving a student’s self-image, ability to interact within a group and problem-solving ability, and concentrates on feelings, values, and self-awareness, and sometimes on personal values and choices (Abadinsky, 2001). “These assumptions are generally implemented through communication training, peer counseling, role playing and assertiveness training” (Abadinsky, 2001, p. 232). Using affective model, adolescents can strengthen their confidence, improve competency of dealing with incidents and have correct value judgment.

Social Influence Model

This model more focuses on decision-making. “The social influence model is centered on external influences that push students toward drug use, especially peer pressure, as well as internal influences, such as the desire to be accepted by ‘the crowd’” (Abadinsky, 2001, p. 229). There are two targets that need to achieve via social influence model. Firstly this model aims to let adolescent to have the awareness of the peer pressures that they are experiencing and secondly to improve their resistance skills for saying no under stress (Abadinsky, 2001).

Treatments for Drug Abuse

There are two main aspects of drug abuse treatments, including chemical treatments and psychological treatments. According to the classification of Abadinsky (2001), chemical treatments contain opioid antagonists, chemicals for detoxification, opioid agonists, chemical responses to cocaine abuse and CRF antagonists. Abadinsky (2001) also mentions that psychological treatments include a psychoanalytic approach, behavior modification and group treatment.

Due to the needs of study and the limit of professional knowledge??this paper mainly focuses on the psychological aspects. Firstly??let us look at the psychoanalytic approach. This approach is very professional and high cost. It is very complicated and difficult to control for social workers. It does not have universality and potential replication. This approach usually applies in some special and serious cases. Then we move on to the behavior modification. There are 4 primary kinds of behavior modification, such as aversion treatment, social learning theory approach, cognitive learning theory approach and contingency management and contingency contracting (Abadinsky, 2001). Although the success rate of aversion treatment is high, it is a kind of compulsive and inhuman therapeutic method, especially for adolescents, no matter in physical or mental sides. This treatment addresses the symptoms, not the cause. Abusers will take drugs again when the aversion conditioned reflex starts to weaken. Contingency management and contingency contracting is outside the scope of this paper’s inquiry. Social learning theory approach and cognitive learning theory approach are referred below. Group treatment is very useful and widespread. It is often used by social workers.

Prevention and intervention plan of adolescents’ drug abuse

There are three dimensions of prevention and intervention plan in this paper. They are macro level, mezzo level and micro level.

Macro level

This level is more about prevention plan. According to the Information Model (Ellickson, 1995), it needs at least tripartite efforts, including school, community and school.

School. Schools should enhance the education of drug abuse and the drug abuse’s hazards, not only verbal and written forms, but also some other lively forms, such as movies and activities. I think the movie Crimson Jade is very shocked one. Maybe schools can find more movies of this kind to show to adolescents. If they know the fearful consequences of drug abuse, they will want to take drugs less.

Community. Actually communities perform a very similar role with schools for the prevention of adolescents. But another thing that communities should pay special attention to is about adolescents’ family situation, especially for the adolescents whose parents have substance abuse problems.

Media. Mass media should play a positive and active role in prevention of adolescents’ drug abuse. Some programmes that focus on drug abuse should be shown regularly. And ground-breaking visual public service advertising of drug abuse should show on TV, newspaper, Internet, even billboard everywhere.

Social influence model (Ellickson, 1995) can be also used in macro level. Schools can make many lectures to let students know that they are all under peer pressures and organize some activities to teach students to develop resistance skills for drug abuse.

Mezzo level

Mezzo level contains prevention plan and intervention plan. It is more about group work. Group approach “is that stimulation toward improvement arises from net work of interpersonal influences in which all members participate” (Northern, 1969, p. 52). Group work is one of the most common work methods for social workers.

Prevention plan of mezzo level. The prevention plan concentrates on affective model. Referring to affective model (Ellickson, 1995), adolescents are divided into groups to do some counseling and training about “affective skills (communication, decision making, self-assertion) believed related to drug use” (Abadinsky, 2001). The counseling and training need the participation of social workers. In this kind of group, social workers should pay special attention to those adolescents who do not want to talk.

Intervention plan of macro level. This intervention plan focuses on group treatment. Due to social workers may not have drug-taking experience, group treatment can make adolescent clients feel more willing to communicate and peer interaction is more powerful (Abadinsky, 2001). In addition, some problematic interpersonal acts will appear in a group (Flores, 1988). Using group treatment, adolescents of drug abuse can “share and identify with others who are going through similar problems; understand their own attitudes about addiction and defenses in others; and learn to communicate needs and feelings more directly” (Flores, 1988, p. 7). Adolescents really need the support from others. Social workers should pay special attention to extreme clients who are not appropriate with group treatment and social workers should ensure a suitable scale of different groups.

Micro level

Micro level more concerns on adolescent abusers themselves and their surroundings. There are two useful intervention approaches with this level – one is social learning theory approach and the other one is cognitive learning theory approach.

Social learning theory approach. Abadinsky (2001) identifies social learning theory as “a variant of behaviorism focuses on cognitive meditational processes and people are active participants in their operant conditioning processes-they determine what is and what is not reinforcing” (p. 205). Actually there are many reasons behind the adolescents who have drug abuse. Maybe there are some problems with their families, their school performance, their interpersonal communication and bodies’ suffering. Social workers must pay more attention to the reasons behind the drug abuse of adolescents and give more patience. So in this intervention, social workers should follow three steps. The first step is to “understand why patients may be more likely to use in a given situation and to understand the role that drugs play in their lives” (Abadinsky, 2001, p. 205). The second step is “to help patients develop meaningful alternative reinforcers to drug abuse, that is, other activities and involvements (relationships, work and hobbies)” (Abadinsky, 2001, p. 205). The third step is to make a detailed examination of the consequences for adolescent clients to test whether their drug abuse reduces (Abadinsky, 2001). Social workers should try their best to find the root causes of adolescents’ drug abuse and cope with them. This approach focuses on the surroundings of adolescent abusers.

Cognitive learning theory approach. This approach emphasizes the awareness of positive and negative consequences of drug abuse for adolescents themselves and the arrangements before taking drugs (Abadinsky, 2001). Social workers can ask adolescent abusers to write a dairy of their drug abuse that includes the situations when they use drugs and the consequences after they use drugs. Social workers ought to inspire clients to review their worst experience with drug abuse and think more about the bad impact of taking drugs. This kind of scare tactic can delay the period before taking drugs. Then social workers also need to teach adolescent abusers a set of relax skills to improve their tension. This approach focuses on adolescent abusers themselves and relies on their own awareness to reduce drug abuse.

Drug abuse of adolescents is really a vicious spiral and a long-term repeated process. It needs not only the social workers’ and adolescent abusers’ efforts, but also their families’, friends’, other relevant persons’ and the whole society’s efforts.

Within the United Kingdom at least one child dies each week resulting from adult cruelty. Statistics from 2003 highlighted that there were over 384,000 children in need in England, and over 69,000 of these children were known to be living in care or living with their families. (Department for Schools and Families, 2003).

Children in need are defined under Section 17 of the Children Act 1989, as those whose vulnerability is such that they are unlikely to reach or maintain satisfactory level of health or development may be significantly impaired without the provision of services.

Practitioners within inter professional roles in local authorities have a duty to safeguard and promote the well being of children (Department for Schools and Families, 2010) and therefore need to be aware of their roles and responsibilities when implementing safeguarding (Lindon, 2008).

The Victoria Climbie report was published in 2003 and highlighted the tragic consequences that led to her death. This eight year old girl was known to the police, social services and the National Health Service over a period of ten months. On twelve of these occasions the relevant statutory services involved had the opportunity to successfully intervene in the life of Victoria. This inquiry highlighted the gaps in incompetence of staff in the statutory services involved in this case by the problems in identifying serious child protection issues, plus the inadequate recording and management of information systems that were in place to safeguard children. These failings were seriously lacking in this case which ultimately contributed to the death of Victoria Climbe (Laming, 2003).

From this inquiry the Department of health (2007) set out the standards in the National Service Framework for Children, Young People and Maternity Services that all agencies work to prevent children suffering harm and to promote their welfare, provide them with the services they require to address their identified needs and safeguard children who are being or who are likely to be harmed.

The following is a quote taken from Laming inquiry:

‘The single most important change in the future must be the drawing of a clear line of accountability, from top to bottom, without doubt or ambiguity about who is responsible at every level for the well-being of vulnerable children. Time and again it was dispiriting to listen to the ‘buck passing’ from those who attempted to justify their positions. For the proper safeguarding of children this must end.’ (Laming, 2003 p.5).

Lord Laming’s inquiry into the death of Victoria Climbie contributed to many significant changes across children’s services in England. The government responded by producing the Green Paper; ‘Every Child Matters’ (Department for Schools and Families, 2003). Many of the proposals in the paper have now passed through parliament and have become legislation in the form of the Adoption and Children Act (2004). The key themes of the Act are supporting families and carers, early intervention and the prevention of children falling through the system, accountability, integrated services, development and training. Section 10 of the Act defines the ‘Every Child Matter’s outcomes which are; be healthy, stay safe, enjoy and achieve, make a positive contribution and achieve economic wellbeing.

The use of integrated approaches/processes for managing concerns about children and their families should result in improved outcomes for this service group. Effective plans for safeguarding and promoting children’s welfare should be based on a wide-ranging assessment of the needs of the child (Department for Schools and Families, 2010).

Resulting from the Green Paper: ‘Every Child Matters (Department for Schools and Families, 2003) the use of an assessment tool known as ‘The Common Assessment Tool’ has been put into practice when working with children and families. The purpose of this tool enables professionals and other services to share information and help identify any additional needs of children which should enhance interagency working. This tool helps to reduce duplication of assessments across different agencies (Department for Schools and Families, 2009).

However, the use of this Common Assessment Tool has been criticised over concerns of security issues regarding access to systems and consent for recording and storing information (Peckover & Hall, 2009).

Every professional or service group that work with children and families are expected to have appropriate core skills to guide their practice. Occupational Therapists are integrated within multi-disciplinary teams across children and families teams and more than often play a lead role in safeguarding this service group. Occupational Therapists have the core skills embedded in their clinical practice to treat all patients holistically. As part of their role is to identify any physical, psychological and any social needs that may be needed through their interventions, in this particular area, children and families, working closely with a child through play and purposeful activities can sometimes highlight any detection of child abuse. This can then be discussed with another member of the multi-disciplinary team and recorded in ‘The Common Assessment Framework Tool’ (COT, 2006).

However what is apparent is that child protection systems do not always work as efficiently as they should without the collaboration and cooperation of the other professionals within all multi-disciplinary teams (Lindon, 2008).

Professionals and other services need to be fully equipped with the knowledge of how other roles in the multi-disciplinary teams work in safeguarding children and families to enable each of them to share information effectively, without these knowledge roles, a breakdown of communication between multi-disciplinary teams is a result.

McNair (2005) states in his literature that professionals can feel threatened by others when encroaching on their territory which can relate to role blurring and crossing over the role of different boundaries.

In conclusion, no amount of legislation and policy guidance absolutely guarantee that child protection services will be able to prevent children slipping through the net. Nonetheless, it is imperative that inter-agency teams working with children and families work collaboratively together to minimise the risks associated with this group of service users. The government has now placed safeguarding children and families at the forefront of their agenda and it is imperative that all professionals can all work together to ensure that this vulnerable group of people are protected.

Critically evaluate the strengths and weaknesses of interprofessional working within social work
Introduction

During the last thirty years there has been a lot of debate over community care. Policy in the 1970s and 1980s brought significant changes to services for people with disabilities, people with learning disabilities, and older people (Kirk, 1998). Many institutions were closed due to financial constraints and care was increasingly focused on the community. In 1988 the Government commissioned the Griffiths Report (1988) which advised that local authorities should be ‘enablers’, organizing and directing community care. Local authorities would have budgets with which to purchase care from the private and voluntary sector.

The 1990 NHS and Community Care Act established that provision of care was no longer the sole responsibility of the state. Care packages would be organised by local authorities with input from voluntary and charitable organisations. Care packages generally consist of one or more of the following; provision of services in a person’s home, residential care, respite care, day care and family placements, sheltered housing and group homes and hostels. The introduction of the 1990 Act increased the burden of care for the social work profession who had to make initial assessments and then refer clients to the appropriate services. This meant that social workers who had previously been quite autonomous in their practice (Challis, 1991). The introduction of new working practices and the necessity for a greater degree of inter-professional working has meant that this autonomy has been increasingly eroded. This paper will examine the strengths and weaknesses of inter-professional working for social workers in the health arena.

Since the introduction of the 1990 Care in the Community Act legislative and policy requirements have focused on health and social care agencies working collaboratively with service users and in July 2005 the Government produced a white paper on the delivery of integrated health and social care.^[1] The main thrust of this paper is to establish effective inter-professional working and the means of evaluating working practice. This is probably in response to the fact that much of the literature concerned with inter-professional working concentrates on the difficulties surrounding successful working relationships between people of different professions and how these problems might best be resolved (Molyneux, 2001).

Molyneux’s (2001)^[2] research into successful inter-professional working established three areas that contributed to the success of such partnerships. Staff needed to be fully committed to what they were doing and personal qualities of adaptability, flexibility and a willingness to share with others were high on the agenda. Regular and positive communication between professionals was seen as endemic to good working relationships and service delivery. This communication was enhanced (in the study) by the instigation of weekly case conferences which allowed professionals to share knowledge and experiences (2001, p.3). Creative working methods, where professionals responded to what was happening in non-traditional ways was also seen as a crucial element of good inter-professional relationships.

In order to be able to work successfully across professional boundaries people need to be confident of their own professional role in order to be able to step outside their professional autonomy and work successfully with others. It helps in inter-professional working if all members of the team are particularly focused on the needs of the service user. In this way people reach ‘professional adulthood’ (Laidler, 1991). Hudson (2005) found in his Birmingham study that inter-professional working went well provided it was based on a parity of esteem, mutual respect and a re-orientation of professional affinity i.e. team members first loyalty was to the team rather than to their individual professional bodies. Hudson also identified communication between members and creativity in working patterns as vital to effective inter-professional working. While Hudson (2005) maintains that there are grounds for optimism as to the future of inter-professional working, he nevertheless points out that it is not always easy. In some areas such as acute services, mental health services or services for older people inter-professional working can be problematic because it is not always easy to decide where one set of professional responsibilities end and another begins. These areas, along with learning disabilities, reflect tensions in integrated working because it poses a threat to established practices. Peck and Norman (1999) found that mental health professionals working within teams were reluctant to obey decisions taken by others because it threatened their own professional judgement. It does not help matters when the Government stresses the need for inter-professional working and then sets separate performance targets, rather than integrated group ones. At the same time as it emphasises collaborative working the Government is now intent on prioritising choice and competition and this leaves professionals with an unstable infrastructure (Hudson, 2001). As Hudson argues:

It would be a cruel irony if, having achieved the holy grail of local integrated working, the government, with Sedgefield’s local MP at its head, now puts in place measures that result in its dismantling (Hudson 2005 no page number).^[3]

Conclusion

Clearly the issues surrounding inter-professional working are not clear cut for social workers. They have lost the professional autonomy that they had in the past and it would seem that some professionals in other areas of social care also find the issues problematic. Clearly professionals from all filed, including social work, do their best to comply with legislation and policy and to collaborate with other professionals. If the goalposts were not consistently shifting in Government discourse then the problems associated with inter-professional working may eventually be ironed out.

References

Griffiths Report (1988) Community Care; An Agenda for Action, London: HMSO

Hudson, B. “Grounds for Optimism” Community Care December 1^st 2005

Kirk, S. 1998 “Trends in community care and patient participation: Implications for the roles of informal carers and community nurses in the United Kingdom” Journal of Advanced Nursing Vol 28 August 1998 Issue 2 p.370

Laidler, P. 1991 “Adults and How to become one” Therapy Weekly 17 (35) p.4

Molyneux, J 2001 “Interprofessional team working: What makes teams work well?” Journal of Inter-professional Care 15 (1) 2001 p.1-7

Norman, I and Peck E. 1999 “Working together in adult community mental health services”: An inter-professional dialogue” Journal of Mental Health 8 (3) June 1999 pp. 217-230

http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4116486&chk=zOTHS/

1

This report will discuss the past and present issues and government policies involved within multi-professional collaborative working as well as discussing how particular training could expand the knowledge of professionals with reference to the various roles of additional agencies. Furthermore it will discuss the various learning theories used to educate professionals in understanding the role of various agencies involved with each service user. In addition this report will discuss exercises that will be used in a training programme developed to deliver inter-professional education to a range of professionals.

Background

Collaborative practice was recognised internationally in 1978 following the Alma-ata declaration which recommended that the work of multidisciplinary teams as well as cost effectiveness and efficiency was of great importance (Allen and Maskarinec, 2008) in order to improve service delivery (Pollard, 2010). Following this, government policies in the UK since the 1980s have insisted that active partnership between the agencies involved within health and social care are imperative and individual reports have since focused on the serious effects that poor multiagency working can have on service users including the Laming report (2003) into the death of Victoria Climbie and the Laming report (2009) into the death of Baby P (Pollard, 2010).

The centre for the advancement of inter-professional education (CAIPE) describes that inter-professional education is imperative to professionals from various agencies in order to come together to understand each role that they will take and what service they can offer with a view to improve quality of care (Barr and Low, 2011).

In order to achieve effective collaboration between the professionals a set of values are instilled which include; the respect by and of each professional, equal opportunities and>>>. Yet Dean and Ballinger (2012) argue that in the case of students many find they lack the time to consolidate the skills of the other professions whilst trying to learn their chosen profession.

Government policies including the green paper Every Child Matters (ECM) 2003 and the children act 2004 include the expectations of the key agencies working together to promote the welfare of children.

Effective Collaboration

Effective collaboration is the coming together of a number of professionals that have a common trust and respect for one another. Together they share the same view in reaching a certain common goal or outcome and work together with a view to achieve that outcome (O’Daniel and Rosenstein, 2008). Rose (2007) argues that working towards a common goal can cause challenging issues between the different professionals such as differing ideologies, cultures and priorities. Rose later suggests that team reasoning theory may help multi-professional working become more effective as the theory proposes that professionals will look more at what is best for the group as opposed to what is best for themselves.

History of failings and barriers in Children’s services

One of the reasons in which children’s services have failed to protect children is due to the lack of information sharing between agencies. In many cases children who are under social services as well as their families are known to a number of agencies such as the police, education establishments and health services such as midwives and health visitors. It is the duty of each professional to share the relevant information with all professionals involved with regards to the child and the family. It is the duty of each professional to share the information in which they have gathered with regards to the child and the family in order to decide on a better outcome for the child. If in any case a professional withhelds the information and the child suffers as a result then that professional will be held accountable.

Services in the past have been criticised for their failure to protect children due to the lack of information sharing between the relevant professionals (Laming, 2003). Following the death of Victoria Climbie services were criticised for missed opportunities and the death of Victoria Climbie was viewed as a tragedy that could have been prevented. As a result of this Lord Laming produced a report into the inquiry of Victoria’s death which contained 108 recommendations and was to later run in accordance with the government green paper Every Child Matters (ECM) (Baker, 2009). Laming believed that it was the role of all involved agencies to protect the child as opposed to a singular agency (Laming, 2003).

The ECM included a framework which sets out key proposals in order to improve services in promoting the wellbeing of the child. Two of the key proposals included were “to develop integrated teams with professionals from all agencies based in and around schools and children’s centres,” as well as to “remove legal technical and cultural barriers to information-sharing and facilitate effective communication” (Hallett, 2004:168).

Following the Laming report and the green paper Every Child Matters the Children act 2004 was implemented which was to include an approach in the way the various agencies shared information to promote the safety and wellbeing of children. Section 11 of the act placed a duty on the significant agencies working with children to understand the necessity to safeguard children (Bokhari, 2012). Whitney (2007) however argues that there are still failings as the duties that are placed on schools are not the same duties that are placed on the other agencies.

The Laming report (2003), ECM (2003) and the Children act 2004 however did not manage to prevent further deaths and again professionals were criticised in their shortcomings when in 2009 Britain was once again left in shock after the tragic death of Peter Connelly (Baby P). Professionals including social workers, doctors, lawyers and police were criticised by BBC news education reporter Katherine Sellgren as incompetent (2010). Sellgren argues in the online news report,

“Baby Peter’s “horrifying death” was down to the incompetence of almost every member of staff who came into contact with him, official reports say.”

The death of Baby P resulted in yet another enquiry into child welfare services in 2009 by Lord Laming. Laming slated social services in the enquiry claiming that “inadequate training” and “poor supervision” were included in the reasons for the failings within the case of Baby P (The Telegraph, 2009).

The reforms made as a result of the death of Victoria Climbie failed to be implemented by social services and the Laming report into the death of Baby P reported that these failings were due to such areas as “impossible targets” (Knapton, 2009) and increased bureaucracy (White et al, 2008).

Inter-professional Education

CAIPE gives the definition of Inter-professional education as,

“Inter-professional Education occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care.” (CAIPE, 2002 as cited in Gopee, 2011:128)

Howkins (2008) argues that continual collaborative practice between health and social care has taken over 30 years and it is as a result of inter-professional education that has amplified and sustained such practice. In order to adapt to inter-professional education it is important to take into account planning as well as time and apposite teaching. Howkins argues the timing of when inter-professional learning should be included in one’s profession and questions the possibilities,

“Is it better to start in the pre-qualifying period with the hope of avoiding the development of negative stereotypes or wait until after the qualification when the professional should feel more confident in their role?” (p1)

The issue with regards to timing has brought about much debate and conversation suggests Howkins. It is also later suggested by Howkins that although there are government policies in place motivating inter-professional education there is little in the way of indication that service user outcomes have improved.

Learning Theories

In order to deliver an effective training plan it is important to include learning theories. Such theories need to relate to adults as they learn differently from children as suggested by Knowles who introduced the adult learning theory, andragogy and argued that as well as adults bringing work and learning skills adults also want to know the purpose of why they need to know something as opposed to children who are presumed to learn what they are being told (Stover, 2006)

Conclusion and Training Plan

This report has discussed the background of inter-professional learning as well as look upon the past failings that have taken place with regards to children as the result of poor collaboration between professionals. An explanation of Inter-professional learning has been deliberated and learning theories have been discussed in order to determine the best approach in order to train professionals to deliver an effective approach to inter-professional learning with a view to achieve the most effective collaboration when working within children and families. Furthermore a plan will be put into place in order to carry out a training session for the relevant professionals with a view to implement the knowledge and importance that interprofessional learning has on children’s services and how effective collaboration between the various agencies can lead to an improved outcome for children

Team Building

Mutual respect and non-hierarchal relationships are the foundations of successful collaborative working. (Kenny, 2002 as cited in Wilson and James, 2007:315)

Inter-professional Education (IPE) occurs when “two or more professions learn together with the object of cultivating collaborative practice” (CAIPE 2002). The benefits, as purported by (Barr 2002) are to have mutual understanding and respect, broadminded attitudes and perceptions and minimised stereotypical thinking. This thinking is informed by the legislative policy requirements of health and social care agencies to work closely and collaboratively together with service user along with professional guidelines (DH 2006, GSCC 2008, and QAA 2008). Communicating with other health and social care professionals, understanding contrasting perspectives, being involved in the seminars, groupwork trigger exercises, and IPE literature has enhanced my learning at the conference and has informed my practice for the future.

The module began with introductions and the team members each described their professional roles. (Dombeck 1997) refers to the importance of knowing your own professional identity and that of others before you are able to be able to form useful IP relationships. As students there was an initial understanding of each of our own professional roles and this was enhanced by discussion. Through this social process of learning we were able to correct each others bias and assumptions. The multidisciplinary group was not universal in its wish to achieve as much from the course as possible; this became understandable later, when it was clarified that the course did not form part of the medical degree qualification. A sense of inequality developed, which led the group to question the value placed on IPE within the medical profession. (Stapleton 1998) refers to open and honest and equal participation being conducive to collaborative relationships between professions. Despite this perceived inequality the group functioned well together. Open and honest discussions ensued although any interactions were superficial given the duration of the conference. Contact was sparse following the conference and there was little use of the IT systems placed on blackboard to assist or cement further learning.

Professor Means (2010) presentation resonated with me, as he spoke of championing one’s own values and ethics, whilst seeing different perspectives and challenging boundaries of roles. He viewed this to be achievable with positive interactions and collaborations and engendering mutual trust and support. This led me to reflect on the nature of this discussion and contribute to the completion of one of our sentences. “Challenging professional boundaries creatively, whilst advocating ones own professions values and ethics.” Pecukonis et al (2008) state that ethics relate to the pursuit of human betterment but these can be viewed and interpreted by different professions and refers to the term profession-centrism.This was underpinned by discussion within the group of the crossover in roles occurring within health and social care for example occupational therapist carrying out some of the duties of nurses and vice versa, whilst also being the ‘eyes and ears’ for social workers. This caused me to consider that social work is done by many professionals and its boundaries are not clear. This, whilst confusing, can lead to more professional fulfilment within roles and lead to a stronger skill mix which, with the service user at the centre, will lead to a better service and resource savings. Social, political and economic elements would welcome this cross over of skills however there is a possibility of a devaluing the value of each profession. (Barr 2004) supports this view and discusses the new flexible worker giving patients a holistic approach but also advocates respect for specialism’s within teams.

The upgrading of responsibility and specialisation of medical tasks to nurses previously in the Doctors domain was discussed and there was a consensus within the group that this was a positive experience as it valued knowledge and not hierarchical structures of power. (Baker et al 2006) discusses the modernisation of healthcare and the move towards a team based model of healthcare delivery. Power has traditionally been sanctioned through authority and has in general been located within the medical profession (Colyer 2004) advises that the last fifteen years have seen a sea change in the medical professions organisation, structure and agency and this has improved the quality of intervention to service users.

The seminar on Intermediate Care by Williams and Drake (2010) increased my knowledge of how the multidisciplinary teams within the Community Health Team and Bristol City Council work together to provide holistic, flexible and client centred services with a single point of access. This occurs despite different IT, communication and reward systems and the challenges for the future viewed as aligning the organisational aims and objectives, recording systems, and professional views to transform consistency, capacity and efficiency. This enabled me to understand the daily pressures of working between organisations and the further challenges that present themselves with the current political and financial changes currently affecting the NHS and how the stereotyping of roles and their responsibilities are changing as are service user involvement.

The terms service user, patient and client were debated by the group and the subtle ways that language inform the discourse. Service user as a term was decided upon as it was the least discriminatory although consensus was not possible and the problematic nature of labels was explored both for service users and carers (Thomas 2010 p.172-3). The National Occupational Standards of Social Work (2006) set out the values and ethics of service users and carers and the importance of inclusion. The carer in the “patients voices” video who expressed her lack of recognition of being an ‘expert by experience’ demonstrated the gaps that as (Payne 2000) defines as the difference between professionals in collaborative working detracting from the empowerment and involvement of people who use services. Service users and carers should have a place in the decision making process.

I was able to appreciate the seminar provide by Adams (2010) which challenged my perception of being different but being compatible with others. Analogies were used of ‘chalk and cheese’ and ‘peas in a pod’; the same components but different .This challenged my own conscious and unconscious views of my own profession and that of others, and the stereotypes that I hold and internalise. In order to combat these feelings I felt a need to have a clear sense of my own identity, confidence, role boundaries, values and ethics and practice and knowledge standards. I questioned my own perceived identity and that of my profession and recognised my own attempts to try to overcome perceived stereotypes and how issues of power and oppression require consideration before action, (Dalrymple and Burke 2006). A discussion ensued regarding conflicts of interest between professionals and I was able to make the links between theory and practice. (White and Featherstone 2005 p.210) explores the idea of story telling about different professions or professional groups and how ‘atrocity’ stories allows one profession to scapegoat another but how stories can also ‘strengthen and confirm identity’, by questioning other professions and thereby strengthening one’s own. (Barnes et al., 2000) state that by developing ones own knowledge base and ‘othering’ of different professions whether rooted in the medical or social models allows different perspectives to be heard and recognised. (Lukes 1974) discusses these views of power and the subtle way that power is exercised and how people can remain powerless and this how service users are viewed within IP practice.

The Childrens Act 1989 and Every Child Matters 2006 are all resulting from the failures within public services to protect children. In reality IPW continues to fail. The Bristol Royal Infirmary (2001) Victoria Climbie Inquiry Lord Laming(2003) and more recent news on the serious case review of Baby P (2009) and the ongoing Mid Staffordshire NHS Trust Inquiry (2010) have highlighted serious breakdowns in multi-agency working and communication. The subsequent media reports have shown increased public mistrust and increased accountability for professionals Davies et al (1999) states that trust is an asset and that its reduction may hamper institutions ability to function.

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Section 2

Discuss how you would take what you have learnt about IP working into practice?

Effective IP working (IPW) involves performing within practice situations of cohesion and disparity. Working collaboratively with other social and health care professionals has experientially helped me to reaffirm and develop my practice. I have gained experience in communicating effectively, understanding teamwork, exploring stereotypes and professional identity and how social, economic and political factors will affect my future practice.

As a social work (SW) student working within an education and child protection setting, I understand the need to ensure a holistic and safe care provision in order to protect vulnerable children and adults. The Victoria Climbie Inquiry (Laming, 2003) pointed to the failure of various professions in their ability to work together in a competent and unified way. The Laming report led to the change in social workers National Occupational Standards and focussed on the need to develop clear documented communication, sharing all aspects with all relevant professionals to avoid any ambiguity and uncertainty within teams. (Laming, 2009. p. 61) emphasises that: ‘there is a clear need for a determined focus on improvement of practice in child protection across all the agencies . . .’ I will describe a child protection team meeting and its wider lessons for my practice.

Whilst on placement I met a young girl, who’s younger brother was subject to a child protection investigation. Her mother had limited English and her father was the alleged abuser. The investigation involved a child protection meeting involving a plethora of health and social care professions to jointly assess the risk to both children. The meeting was effectively chaired by a social worker and all were invited to contribute their specific knowledge and evidence on the family, opinion was sought on actions and timeframes.(Molyneux 2001) debates the issue of good teamwork as being dependant on the qualities of the staff and the need for there to be no one dominant force. By communication being inclusive, creative and regular, issues can be debated and resolved. Concluding that teams were successful when members were confident, motivated and flexible and communication channels were clear, frequent and in the same base. (Petrie 1976) discusses a cognitive map where two opposing disciplinarians can look at the same thing but not see the same thing. My experience of working within this multi-disciplinary team was positive with all professionals having a voice. However on reflection and through IPW I am now more aware of the perspectives of others and the need to define and develop my professional identity. (Bell & Allain 2010 p.10) in their pedagogic study allude to SW students being reverential to medical expertise and giving low ratings on their own abilities of leadership. I feel a dichotomy exists between SW railing against the medical model and promoting the social model whilst deferring to the stereotypes of professionalism within health and social care. For the future I need to be aware of stereotypes and continue to develop my critical reflection of both my personal and professional self whilst developing my abilities to be heard within multiprofessional teams.

As a SW student, I am aware that there exists a blurring of edges of what the SW role entails and how the identity of the role may change in the future. (Payne2006) refers to a social worker working within a mental health practitioners’ team which included working alongside nurses and psychologists including high levels of therapy based work, which would not usually sit within social work practice and therefore one’s professional identity could be lost. (Lymbury & Butler 2004) state that whilst it is important to share knowledge with other professionals that are allied to social work it is imperative that the identity of one’s own profession is preserved. (Laidler 1991) further addresses the issues of crossing professional boundaries describing them as ‘professional adulthood’. That IP jealousy and conflicts will arise to the detriment of the team members and more importantly to the service user. Power as exercised may cause some to struggle as power is shared and fluctuates in accordance with whose knowledge and expertise best suits the service user. Envy as discussed by (Schein 2004) identifies ways in which it can stand in the way of good IP learning by creating a collective unconscious resulting in; an attack on colleagues, an attack on learning and failing to learn from each other and or authority figures, and issues of who takes responsibility. Within the Child Protection meeting the chair was a senior SW who co-ordinated the professionals and this caused me to reflect on my abilities, as SWs must deliver safe high quality care but given limited resources , different professional groups will have different priorities and see issues differently. Sellman (2010) concludes that you need to be willing , have trust in others and have effective leadership either acting with your inclinations or action that affords the best outcome however, personal , professional and structural influences can encourage or discourage practitioners. I recognised that for the future I needed to increase my ability to create a dialogue across difference whilst holding on to the dignity and responsibility of every person. (Skaerbaek 2010) purports that by listening to the minority one is able to see the practices that underlie the agenda of the majority.

However the future blurring of health and welfare provision is changing across all sectors. The role of the private sector in the provision of health and welfare practice can provide competitive market forces to drive up the standards and offer greater choice to individuals through direct payments. This in turn can create greater service user autonomy and much more creative solutions. However this can also lead to inequality and a perception that the services are driven by profit bringing the ethical motivation of private sector into question and a blurring of the duties of the state to the service user. (Field and Peck 2003) conclude that the culture of the private and public sector will need to merge and this will result in challenges within roles and organisations. The voluntary sector is one of the fastest growing with voluntary organisations, who, when commissioned, are more accessible to service users and people are more likely to engage with them. They have more freedom acting as advocates and campaigners and are less regulated through targets (Pollard et al 2010). However given the current economic climate and the recently announced budget cuts (Rickets 2010) suggests that the pressure on the voluntary sector to provide more services will continue and if the state retreats from providing services, the voluntary and community sector will fill the gap. Personalisation in which services are tailored to the needs and preferences of citizens is the overall government vision: that the state should empower citizens to shape their own lives and the services they receive. Liberating the NHS 2010 (p3 & 4) states that “We will put patients at the heart of the NHS, through an information revolution and greater choice and control: a. Shared decision making will become the norm: no decision about me without me” and “The Government will devolve power and responsibility for commissioning services to the healthcare professionals closest to patients: GP’s and their practice teams working in consortia.”(Foreman 2008) sees the need to involve IT in helping to improve and reduce the barriers to IPW. The structures of IPW will continue to evolve and change with complexity and ideological thinking however I need to engage with other professionals and service users in a person centred way.

In conclusion, the IPW conference, literature and subsequent research have clarified my future need to be flexible in both my role and that of others and the primacy of the service user at the centre of my practice. Teams and service users are diverse, comprised of people of different ages, from different social and cultural backgrounds with different expectations. (Carnwell et al 2005 p.56) relates collaboration to embracing diversity and moving away from the comfortable assumption that there is only one way to see the world , providing strategies : learn from each other, embrace IP working, and adopt a value position where anti discriminatory practice is central. By critically reflecting on practice I must embrace a degree of uncertainty and unpredictability as a necessary part of the complex micro and macro systems of IPW.

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SECTION 3 – REFERENCES

Adams, K. (2010) What is Interprofessional Education? UWE Bristol, IPE Level 2 Conference.

Baker, D. Day, R. Salas, E. (2006) Teamwork as an essential component of high reliability organizations. Health Services Research 41(4) pp 1576-98.

Barnes, D., Carpenter, J. & Dickinson, C. (2000) ‘Inter-professional education for community mental health: attitudes to community care and professional stereotypes’, Social Work Education. Vol 19 (6), pp. 565-583.

Haringey Safeguarding Children Board Serious Case Review: Baby Peter Executive Summary (2009).[online] Available from:

http://www.haringeylscb.org/executive_summary_peter_final.pdf [Accessed 22 November 2010]

Barr ,H. (2002) Interprofessional Education Today, Yesterday and Tomorrow: A Review. LTSN HS & P: London.

Barr, H., Freeth, D., Hammick, M., Koppel, I. & Reeves, S. (2000) Evaluations of Interprofessional Education: A United Kingdom Review for Health and Social Care. CAIPE/BERA: London.

Bell, L. and Allain, L. (2010) Exploring Professional Stereotypes and Learning for Interprofessional Practice: An Example from UK Qualifying Level. Social Work Education. Vol 1 pp1 -15

Bristol Royal Infirmary Inquiry HM Government (2001) Learning from Bristol: the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984 -1995. London: HMSO [online] Available from:

http://www.bristol-inquiry.org.uk/final_report/report/index.htm [Accessed 16 November 2010]

Carnwell, R. Buchanan, J. (2005) Effective Practice in Health & Social Care: A partnership Approach. Berkshire: Open University Press

CAIPE (2002) [online] Available from : http://www.caipe.org.uk/about-us/defining-ipe/ [Accessed 8 November 2010]

Childrens Act (1989) [online] Available from: http://www.legislation.gov.uk/ukpga/1989/41/contents [Accessed 10 November 2010]

Colyer, H. (2004) The construction and development of health professions: where will it end? Journal of Advanced Nursing Vol 48, (4), pp. 408-412

Dalrymple, J. and Burke, B. (2006) Anti-oppressive Practice, Social Care and the Law (2nd edition). Maidenhead: Open University Press

Davies, H. & Shields, A. (1999) Public trust and accountability for clinical performance; lessons from the national press reportage of the Bristol hearing. Journal of Evaluation in Clinical practice. Vol 5,(3) pp. 335-342.

Department of Health (DH) (2006) Options for Excellence- Building the Social care Workforce of the future TSO: London

Dombeck, M. (1997) Professional personhood:training, territoriality and tolerance. Journal of Interprofessional Care, 11 pp. 9-21.

Field, J & Peck, E. (2003) Public-private partnerships in healthcare: the managers’ perspective. Health and Social Care in the Community. Vol 11 pp.494-501

Foreman, D. (2008) Using technology to overcome some traditional barriers to effective clinical interprofessional learning. Journal of Interprofessional Care, Vol 22(2) pp.209-211.

General Social Care Council (2008) Social Work at its Best: A Statement of Social Work Roles and Tasks for the 21st Century [online]. Available at http://www.gscc.org.uk [Accessed 18 November 2010]

HM Government (2004) Every Child Matters: Change for Children 2004. London: HMSO [online] Available from:

http://www.opsi.gov.uk/Acts/acts2004/ukpga_20040031_en_1 [Accessed 19 November 2010]

HM Government (2010) Equity and excellence: Liberating the NHS. London: HMSO [online] Available from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117794.pdf [Accessed 19 November 2010]

Haringey Safeguarding Children Board Serious Case Review: Baby Peter Executive Summary (2009).[online] Available from:

http://www.haringeylscb.org/executive_summary_peter_final.pdf [Accessed 22 November 2010]

Keeping, C. & Barratt, G. 2009 Interprofessional Practice cited in Glasby, J & Dickenson H (2009) International Perspectives on Health and Social Care Oxford Wiley- Blackwell.

Laidler, P. (1991) Adults, and how to become one. Therapy Weekly. Vol 17 (35) p4.

Laming, Lord (2003) The Victoria Climbie Inquiry. Stationery Office, London

Laming, Lord (2009) The Protection of Children in England: A Progress Report. Stationery Office: London

Lukes, S. (1974) Power: A Radical View Basingstoke: Macmillan

Lymbury, M. and Butler, S. (2004) Social work ideals and practice realities. Basingstoke: Palgrave Macmillan

Means, R. (2010) Why Inter-professional Working Matters: From Theory To Practice UWE Bristol, IPE Level 2 Conference.

Mid Staffordshire NHS Foundation Trust Public Inquiry (2010) [online] Available from: http://www.midstaffspublicinquiry.com/ [Accessed 22 November 2010]

Molyneux J (2001) Interprofessional teamworking: what makes teams work well? Journal of Interprofessional Care. 15,(1), pp.338-346

Payne, M. (2006) What is professional social work? Bristol: Polity Press

Pecukonis E, Doyle O, Bliss DL (2008) Reducing barriers to interprofessional training: promoting interprofessional cultural competence. Journal of Interprofessional Care Vol 22 pp.417-28

Petrie, H . G. (1976) Do you see what I see? The epistemology of interdisciplinary inquiry. Journal of Aesthetic Education, 10, 29 – 43.

Pollard, K. Thomas, J. and Miers, M. (2010) Understanding Interprofessional Working in Health and Social Care. Basingstoke: Palgrave Macmillan

Quality Assurance Agency (QAA) (2008) Social Work Benchmark Statements [online]. Available at:

http://qaa.ac.uk/academicinfrastructure/benchmark/statements/socialwork08.asp.

[Accessed 15 November 2010]

Rickets, A. (2010) Budget will place major burden on charities. Third Sector [online] Available at: http://www.thirdsector.co.uk/News/DailyBulletin/1011592/Budget-will-place-major-burden-charities-umbrella-bodies- [Accessed 20 November 2010]

Schein, E. (2004) Organizational Culture and Leadership. San Francisco: Jossey-Bass.

Sellman D. (2010) Values and Ethics in Interprofessional Working In Pollard K. Thomas J, Miers, M.(eds) (2010) Understanding Interprofessional Working in Health and Social Care Basingstoke: Palgrave MacMillan

Skaerbaek, E. (2010) Undressing the Emperor? On the ethical dilemmas of heirarchical knowledge Journal of Interprofessional Care, September2010; 24(5) : 579-586

Skills for Care (2006) National Occupational Standards for Social Work. [online]. Available at: http://www.skillsforcare.org.uk (Accessed 19 November 2010).

Stapleton, S. (1998) Team-building: making collaborative practice work. Journal of Nurse-Midwifery 43(1), pp12-18

Thomas, J (2010) Service Users, Carers and Issues for Collaborative Practice cited in Pollard, K, Thomas, J and Miers, M. Understanding Interprofessional Working in Health and Social Car Basingstoke: Palgrave Macmillan.

White, S. & Featherstone, B. (2005) ‘Communicating misunderstandings: multi-agency work as social practice’, Child and Family Social Work, Vol. 10, pp. 207-216

Williams, V. and Drake, S. (2010) Intermediate Care (IMCS) Bridging the Gap Facilitated Discharge. UWE Bristol, IPE Level 2 Conference.

SECTION 4
APPENDIX- 6 AGREED GROUP SENTENCES

Theme 1: Communication issues between Health and Social Care professionals

Clear and concise communication is key to a well co-ordinated transfer within health and social care services.

Health and Social care professionals need to recognise the importance of maintaining privacy, dignity and respect when communicating in the presence of service users.

Theme 2: Contrasting professional perspectives/ values within teams.

Recognise the importance of valuing each health and social care professions perspective.

Challenging professional boundaries creatively whilst advocating ones own professions values and ethics.

Theme 3: Stereotyping, power imbalances and team processes

Positive attitudes to working with other health and social care professionals in a real world environment with the patient/service user at the centre of planning and documenting is necessary to reduce power imbalances.

Recognise and embrace differences to minimise stereotypical views within health and social care.

Interprofessional Collaboration in Health and Social Care is changing the face of service delivery based on government’s attraction to this concept. This essay is an attempt to identify and evaluate weaknesses that affect interprofessional working, using a practice based critical incident (see Appendix A). In order to achieve this, a model of critical reflection, a combination of systematic analytical tools (SWOT, PESTEL) and use of relevant theories are adopted to unearth various assumptions and their sources with a view of engaging the application of theory to practice which will consequently improve provision of services to end users in practice with the added benefit of improving interprofessional working.

The various influencing factors identified from the analysis that conflate in the arena of interprofessionalism makes it a very complex, yet desirable concept to embrace and implement for the effective delivery of service within health and social care.

The case for a Model of Critical reflection

Reflection has been defined as “a process of reviewing an experience of practice in order to describe, analyse, evaluate and so inform learning about practice” Reid (1993). Researching various models of critical reflection (Gibbs reflective cycle (1988), Stephenson’s framework of reflection (1993), Fook and Askeland (2006) indicated a number of variables which are relevant in the evaluation and reflection on practice situation. For the purpose of this particular case study, I have chosen to reflect on the critical incident described in Appendix A by using Fook’s model of critical reflection. This model;

Focuses on identifying underlying assumptions with a specific purpose of fostering improvement in professional practice Fook and Askeland (2006,p),

Highlights power as a critical element of transforming the revealed assumptions with a view to create a positive change in the practice situation.

The concept of power in critical reflection is relevant in the social, cultural, professional and political context with the aim of gaining a sense of personal power therefore more control and choice, through the exposure of dominant assumptions in operation. Fook (2006), Foucault (1983) cited in White et al (2006, p44).

Fook’s model enables reflection on awareness and use of power in the course of performing my professional role. Fook also emphasises the place of emotion, communication, dialogue and learning in this model of critical reflection. This is particularly relevant to the practice situation as it led to competence queries in the light of the ensuing reverberation. This model of critical reflection is a valuable tool, enabling better decision-making, improved ability to work with uncertainty and multiple perspectives, resolve dilemmas, recognising the use and power of emotion, and better ability to learn from practice. Fook and Askeland (2006)

My choice of Fook’s critical reflection model helps me to take a look at what I do, why I do it, unearthing relevant hidden assumptions influenced by my cultural, social, professional and political beliefs (see PESTEL analysis in Appendix C). It also enables me to reframe myself in view of the revealed assumptions behind my thinking that affects my practice. This model seeks to empower by giving choices and creating new knowledge when the process of reflection is practised. It could also potentially reaffirm personal beliefs that may have been previously separated from professional roles which inadvertently create conflict.

Interprofessional Concept

Interprofessional concepts that are apparently relevant to the practice situation are collaboration and communication. The key weaknesses identified were due to lack of communication and failings in collaboration between the pharmacy, social services professions and general practitioner (GP) engaged in the care of the older people in the community.

In order to analyse the practice situation, two analytical tools are adopted namely –

SWOT analysis – considers the strengths and weaknesses in the case and also the opportunity and threats embedded in it. (Appendix B).

PESTEL analysis – This tool relates the situation to its external environmental factors with a view to identifying influences and impacts of the environment.( Appendix C)

The two major areas of weakness focused on are:

The gaps in collaboration between pharmacist, social workers and GPs in the community.

Poor communication between Health and Social Care (HS&C) professionals in the community.

Literature Review

The concept of interprofessional collaboration has been defined as working together with one or more members of the health care team where each makes a unique contribution to achieving a common goal. Each individual contributes from within the limits of his/her scope of practice. Broers et al (2009), College of Nurses Ontario (2008), Makowsky et al (2009). The Health and Social care policy on ‘joined up working’ Department of Health (DoH 2000) has been regarded as a major document pointing the way to or representing one of the imperatives for the ‘modernisation’ agenda. Health and Social Care policies has witnessed several changes in the last twenty five years with a shift in focus from institutional to community care with an attendant upsurge in service commissioning, which created an increasing role for primary care. Karban & Smith (2006).

The need for greater collaboration and communication has been highlighted by the recent increase in major enquiries into several aspects of health and social care (Victoria Climbie inquiry report by Laming (2003), Baby P’s case). Loxley (1995) asserted that the recognition of health and welfare within society as an interactive, adaptive process without an end becomes the only creative basis for strategies, policies and practices and as such, the ability to collaborate is thus an essential in this interactive process.

The National Service Framework for Older people DoH (2001) clearly demands that the NHS and local authorities work in partnership to promote health ageing and prevent disease in older people. DoH (2001). Various government policies has emphasised partnership and joint working as the main focus to drive improved care to users of health and social care services. DoH (1998a) Partnership in Action (1998b); Working Together (1998c); First class service; quality in the new NHS)

Leathard’s(2003) review on McGrath’s (1991) study on interprofessional teamwork in Wales found that joint working led to more efficient use of staff, efficient service provision and a more satisfying work environment. Other benefits include the value of knowledge sharing, potential for comprehensively integrated services, efficient use of public funds and the avoidance of duplication and gaps in services. The New NHS-modern and dependable: DoH (1998).

The government’s objective is to build a reliable health service where patients have access to high quality services based on identified need, building on integrated care between health and social care where each have equally important roles to play. The White paper (1998) sets out the framework for the partnership, with the intention to remove barriers to effective collaboration in the existing systems and provide new incentives for joint working across agencies.

The role of Pharmacists in interprofessional collaboration.

The pharmacy profession’s code of ethics is traditionally based on the medical model of health, where duty of care is to the patient and mainly prescriptive and paternalistic. Naidoo and Wills (2009). There are no strong evidences to support joint working between community pharmacy and other health and social professions despite a strong need for collaboration for the delivery of excellent patient care across the primary and secondary interface. Makowsky et al (2009) review indicates that collaborative working relationships between nurses and physicians have been the focus of several researches, but relatively little work has investigated the integration and nature of collaborative relationships pharmacists have with other health care practitioners. The review stated that most investigations into professional relationship between pharmacy and other healthcare profession has been on physician’s satisfaction attitudes or perceptions towards specific aspects of pharmacy practice, pharmacist roles, perceived barriers between physicians and community pharmacists, unmet needs in the medication use process, physician expectations of pharmacist and physician’s receptiveness to clinical pharmacists.

‘Competencies of the Future Pharmacy workforce’ a publication by the Royal Pharmaceutical Society of Great Britain (2003/2004) highlights the need for greater levels of collaboration between pharmacists across all sectors and boundaries as the way forward for relevance within the healthcare workforce. The Pharmacy White paper (year) also emphasised the role of pharmacists in providing services in the present NHS structure and this would necessitate a greater awareness and participatory collaboration with other healthcare professionals.

Barriers to Interprofessional Collaboration

In spite of the laudable and apparently desirable benefits of interprofessional collaboration, in reality there are barriers that limit effectiveness of this concept between health and social care professionals as apparent in my practice situation. Historically, barriers such as professional cultures, different forms of accountabilities between health and social services, political agendas, rigid boundaries, departmental survival existed and still remain to challenge present day twenty-first century health and social care. Hardy et al (1992) cited in Leathard (2003) identified five categories of the challenges facing joint working within health and social care as;

Structural issues such as service fragmentation, gaps in services.

Procedural matters which hinders joint planning through different budgetary planning cycles and procedures.

Financial factors such as different funding mechanisms, administrative and communication costs

Status and legitimacy, for example local responsibilities are based within a democratically elected arena and in contrast, all services are commissioned and centrally run by the NHS.

Professional issues which include problems associated with conflicting views and ideologies about users, professional self-interest, competition for domains, as well as differences between expertise, specialism and skills.

Leathard (2003) noted more barriers such as practitioners isolated with little management support, inequalities in status and salary, differing leadership styles, lack of clarity about roles as damaging to inter professional collaboration.

It has been noted that service users and carers as typified by the examples in the practice situation (see appendix A) often experience frustration and distress in trying to organise the type of care they want or support needed as a carer. This process, involving contact with different agencies and each with different assessment processes, often leave users and carers unclear as to who should be doing what and how it all links together. DoH (1998a)

Joint working has been identified by the DoH (1998) as needed at three levels; strategic planning, service commissioning and service provision. In the practice of pharmacy in the care of the community, service provision must deliver an integrated package that avoids the burden of complex bureaucracy.

Barriers to Joint Working: Communication

Another weakness identified in the SWOT analysis, (see Appendix C) is poor communication. Information sharing in the appropriate context is important in helping to promote informed decision making and aid the provision of user-focused care. On the other hand, incorrect information can destroy or reinforce negative or destructive stereotypes and therefore limit the range of options offered to the user. Hammick et al (2009). Poor communication can be a barrier to effective information sharing in professional practice. The lack of clarity in the process of communication experience in my context can also be down lack of awareness of how the agencies work together. Meads et al (2005) states that poor systems and lack of parity between different professionals can be major risk factors, particularly with regards to effective communication. In the inquiries into the events that led to Victoria Climbie’s death in 2000 and the Bristol Royal Infirmary incident, systemic failures that led to poor communications were highlighted.

The issue of communication was further complicated by the fact that I had no prior knowledge of any disability suffered by the patient that would necessitate any form of assessment set out by the Disability Discrimination Act (2004), I assumed that the client’s GP would be aware of the process of referral for patients needing support with their medicines as they are usually their first point of call. Carer’s expectation was that all service providers talked to each other in a way that gets things done smoothly. Reflecting on what I have learnt on interprofessional collaboration, the situation became clearer as I realised that different organisations have different operating procedures which, despite attempts at collaboration, can still be conflicting.

External influences on the practice situation such as legal factors (see Appendix C) include issues such as patient confidentiality and data protection requirements which make it imperative that proper channels of communication are followed to protect clients’ privacy. This raises ethical and legal questions on how much is too much or too little to exchange with other agencies.

I have learnt that the failings in the practice situation described is not a clear cut failing by a single person, but a classic example of how the barriers to interprofessional working can have a direct impact on both the service user and provider.

Systems Approach to Joint Working: A resolve

A systemic approach to collaboration as stated by Payne(1997) in Hammick et al(2009) is relevant to interprofessional practice as it sees individuals as social beings, affected by and influencing others around them, the organisations with which they have contact and the wider society, drawing attention to relationships, structure, processes and interdependence.

The whole systems concept developed by Bertanlanffy (1971) describes the exchange across permeable boundaries between systems and environments. This characteristic of the systems theory is crucial in its application to service organisations, like the NHS and social service. The key elements from the systems theory as concurred to by Loxley(1997) and Willumsen (2008)relevant to understanding collaboration in interprofessional practice is interdependence and interaction, emphasis on management of processes, the recognition of equifinality – the achievement of the same goal from different starting points. Loxley (1997) asserts that it is possible to manage complexity and differences through the recognition and use of common properties which apply to both parts and to a whole when experiences are shared.

For the whole systems approach to work, the right conditions as advocated by Maddock and Morgan (1999) in Leathard (2003) include;

Support for communication between users and frontline staff

Involvement of actively committed staff

Appropriate performance measures supporting change and staff development

Management and practitioners sharing the same agenda on quality and funding issues

A senior management team with a unity of vision.

The benefits of the whole systems approach as shown by the study on delivery of services to older people across health and social care in Brighton and Hove, Sussex Callanan (2001) include; initiatives to identify gaps in services, an improvement in the services provided in the multidisciplinary assessment and review, improved flexibility to meet user’s needs and the enabling of small changes which would result in significant improvements in service provision. The whole systems approach with the theorised benefits is not without its limitations. CSIP(Care Service Improvement Partnership) Older People Team cited in the ‘whole systems approach’ , a document paper by the NHS Wales(2006) concluded that for most places, a whole systems approach is a statement of aspiration rather than a statement of achievement as there are limitations inherent in the approach.

Conclusion

The way forward may be more opportunities for joint learning among health and social care professionals in practice. Integrating joint learning in the whole systems approach to effective collaboration might in some way resolve some of the perceived barriers.

Learning together reflectively will challenge traditional barriers, professional barriers and compartmentalised thinking. Karban and Smith (2006). They argued that a model of critical and reflective practice acquired through learning together will enable future practitioners develop a shared understanding of the world and ways of working together based on creating a shared dialogue within communities of practice that will enhance the experience of service users.

Forming multidisciplinary teams in the care of the community for specific target population may also be effective in closing the gap in collaboration between pharmacy and other health and social care profession.

In order to avoid the reoccurrence of the incident discussed in my practice situation, I will seek to implement the following –

Raise awareness/understanding of referral process among professionals engaged in the management of older people with disability by writing a letter to all agencies concerned.

Organise seminars at local GP meetings with other healthcare professionals involved in the care of older people with the view of clarifying the referral procedures for effective provision of service

This assignment will critically analyse two examples of interprofessional and interagency practice using examples from my current practice placement. Relevant literature will be used to identify what factors support or constrain interprofessional and interagency collaboration (IPIAC). IPIAC is often described as a holistic approach to an individual’s needs. When used effectively, a holistic approach allows for better service delivery to the service user. Hammick et al (2009, p.10) states that being interprofessional is “learning and working or working and learning with others as appropriate, when necessary and sometimes both”. Interagency working concentrates “more on the organisational roles and responsibilities of those involved in collaboration” (http://www.scie.org.uk). Interprofessional is relationships between individuals and interagency is relationships between organisations.

IPIAC was a modernisation agenda introduced in public policy by the New Labour Government. Government recognition suggests that many social problems cannot be effectively addressed by any given organisation acting in isolation from others. That is, when professionals work together effectively they provide a better service to the complex needs of the most vulnerable people in society. New Labour also specified that there was a ‘Berlin Wall’ type division between agencies and professionals and that there was a barrier to co-operation and this barrier should be confronted so that services worked in partnership with service users. However according to research conducted by Hiscock and Pearson (2002, p.11) “several government reports have criticised the lack of coordination between health and social services in the community”. So, in essence when professions work collaboratively the service user gets a better deal. “Willing participation” (Henneman et al, 1995, cited in Barrett et al, 2005, p.19) and a “high level of motivation” (Molyneux, 2001, cited in Barrett et al, p.19) have been stated as vital aspects of effective IPIAC.

My current practice placement is within a voluntary organisation in a domestic abuse service. I am a project worker at a Refuge for women and children who are escaping domestic abuse. My role is to co-link work with permanent Refuge staff and co-ordinate each service users support needs whilst maintaining links with appropriate statutory and voluntary sectors.

INTERPROFESSIONAL PRACTICE ONE

The first example of IPIAC to be discussed and analysed within my practice placement will be a weekly meeting held between Refuge staff, health visitors and the play-worker from Women’s Aid. The aim and purpose of these meetings is to share information so that identified needs of the families in the Refuge can be addressed and where possible be signposted to other services as required. The meetings are designed for professionals to share information and knowledge about the family’s lives but not make decisions on their behalf (except where there are child protection issues). The meetings also aim to provide support to families according to assessment of need using professional judgement. Within these meetings everyone discusses and communicates the personal development and progress of the women and children in the Refuge so that all professions involved are kept up to date with the family’s circumstances and situation. This supports IPIAC and is effective in that it is a chance for everyone involved to gain further advice and guidance from other professionals in relation to their current level of involvement with the families. This in turn supports the families and assists them with their future goals and plans. However these meetings could be interpreted to some as ‘secretive’ as they are held behind closed doors and it is a meeting in which the families are not involved in. This could be construed as an ‘expert power relationship’ to some (Maclean and Harrison, 2011, p.31).

For IPIAC and these meetings to be effective it is vital that all professionals involved support one another and are not be seen as self-interested or see themselves as higher than another profession. This is when problems occur as there is not a logical distribution of power. “Unequal power distribution can be oppressive” (Payne, 2000, cited in Barrett et al, 2005, p.23) and can limit participation for some professionals. Power in IPIAC should be shared and distributed and no hierarchy of power should exist. If some professionals see themselves as more powerful than another they are not meeting the needs of the service user. Sharing of information and knowledge about the families in the Refuge is the purpose of these weekly meetings so as to achieve the best possible outcome for the service user.

A constraint of IPIAC is that some professionals are territorial and do not like to share information and knowledge. Molyneux (2001, cited in Barrett et al, 2005, p20) “found that professionals who were confident in their own role were able to work flexibly across professional boundaries without feeling jealous or threatened”. “Professional adulthood” was an expression used by Laidler (1991, cited in Barrett et al, 2005, p.20) to describe professionals who were confident in their own role to share information and communicate effectively with other professionals. These professionals do not feel territorial about relinquishing their knowledge and understanding to further enhance good IPIAC. Stapleton (1998, cited in Barrett et al, 2005, p.20) suggests that “a combination of personal and professional confidence enables individuals to assert their own perspectives and challenge the viewpoints of others”.

Active listening is an important skill to maintain in order to achieve effective IPIAC. To be able to recognise and respond to what is being communicated is fundamental. Professionals working collaboratively should be able to demonstrate this verbally and non-verbally to each other. This is greatly helped if all concerned put aside the typical stereotyping of each other’s professions in order to hear and listen to what is being said. Effective open and honest communication is vital and probably one of the most important aspects of IPIAC. It requires professionals to take into account each other’s views, be respectful, dignified and to listen to each other without being highly critical of one another. Constructive feedback about the family needs to be undertaken alongside constructive suggestions and encouragement and should take place at a time when other professionals are receptive. However, being receptive to what is being said does not always occur during these meetings. At times, one professional does not like what another is conveying and this can create conflict within the professions. However the need here is to remember that it is the service user that is central to the process and that the goal is to achieve the best outcome for them and their family.

There are elements within this example that both support and constrain IPIAC. To achieve the goal and not result in a poor outcome for the service user it is important for all professionals involved to communicate honestly and openly and for there to not be a significant power imbalance between the professions.

INTERPROFESSIONAL PRACTICE TWO

The second example of IPIAC to be discussed and analysed within my practice placement will be a Multi-Agency Risk Assessment Conference (MARAC). A member of the Refuge staff attends these meetings on a fortnightly basis. A MARAC meeting is a community response to domestic abuse. Cases are referred to a MARAC by the Refuge as a result of completing a CAADA-DASH risk identification checklist (RIC) (see appendix one) with the victim of the domestic abuse. This checklist determines the victim’s level of risk/need. If the risk identification score is 14 or more on the RIC, the MARAC threshold for high-risk has been meet and a referral to a MARAC meeting is made. Cases can also be referred to the MARAC either as a result of a high risk domestic crime/incident recorded by the police or by a direct referral from a participating agency. Participating agencies attending the meetings can include representatives of statutory services such as the police, criminal justice, health, child protection, housing practitioners and Independent Domestic Violence Advocates (IDVA’s). The purpose of the meetings is for professionals to implement a risk management plan that provides professional support to all those at risk and which reduces the risk of harm. The aim is then to produce a safety plan for each victim of domestic abuse.

The MARAC’s aim is to share information to increase the safety, health and well-being of victims/survivors of domestic abuse. They can determine whether the alleged perpetrator poses a significant risk to any particular individual or to the general community. According to Bowen (2011, chapter 5.) “MARAC functions through meetings designed to facilitate multi-agency information sharing, with a view to implementing an agreed-upon risk management and victim safety plan”. Effective communication and information sharing supports IPIAC as it can assist to build relationships between agencies across a much broader range. A MARAC with effective communication and information sharing between agencies can also promote IPIAC in developing much stronger relationships between the voluntary and statutory sector. Barrett et el (2008, p.21) states that “communication competence contributes to effective interprofessional working and enables those involved to articulate their own perspectives, listen to the views of others and negotiate outcomes”. An effective MARAC meeting which supports IPIAC is when professionals work collaboratively to ensure that victims/survivors and/or their children are safeguarded from further abuse. The government’s action plan “Call to End All Violence Against Women and Girls” states that “we all have to work together to achieve our goal of ending violence against women and girls. It is not a task for central government alone”. It suggests that agencies need to work together to meet the needs of their local communities and that agencies are held accountable.

However, a constraint of a MARAC meeting that I witnessed was that not all professionals brought the appropriate information to the meetings which lead to an inefficiency and delay of the case which frustrated others professionals attending. Poor timekeeping was another avenue that at times would frustrate other professionals attending the meetings. This seemed to alienate them as I would hear comments such as “we are all professionals here and should act as such” and “as professionals attending important meetings like this, we should always strive to be on time”. I also found at the MARAC that some agencies only had snippets of information that on their own did not raise any particular concern. It was only when the jigsaw of information was pieced together that the risk factors could begin to be understood.

This example shows that when MARAC meetings support and strengthen interagency working and is effective, it is IPIAC at its best. This approach to working more collaboratively is beneficial as all organisations are coming together for the purpose of a common goal, with that goal being the best possible outcome for the service user. However some of the MARAC meetings that I had attended were not always that effective due to the fact that not all key agencies or organisations attended the meetings when required to do so or did not have the appropriate information to hand. It is beneficial that all agencies have as much information to hand as possible to facilitate IPIAC and have a profound positive impact on the outcome for the service user.

In conclusion, IPIAC has many elements and all these different elements require that the different professions adopt them so that effective outcomes are achieved for the service user. Although IPIAC has been around for many years and is not new, it still needs to be continued, developed and incorporated into the daily work of all professions. When organisations and professions from different disciplines truly understand each other’s roles, responsibilities and challenges, the potential of IPIAC could be fully realised and many of the barriers alleviated. This in turn will contribute to a more successful outcome to the service user which of course is central to effective IPIAC. If IPIAC is ineffective it can limit choice for the service user and also increase risk.

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Establishing Internal Validity in Longitudinal Research with the Homeless

Introduction

When working with the homeless, it is necessary to identify potential factors that may contribute to the process of entering or exiting homelessness. These factors may take the form of demographic information, socio-economic status, and familial support, to name a few (Johnson et al., 1997; Chamberlain & Johnson, 2013). Some of these variables may be described as negative reinforcements, in that they exacerbate a person’s likelihood of experiencing prolonged homelessness (Aubry, Klodawsky, & Coulombe, 2012). These may include substance use, mental illness, arrest history, and absence of support network (Fazel et al., 2008). The temporal relationship between variables of this nature and homelessness is of particular interest to researchers. Determining whether substance use or mental illness precede and predict one’s chances of entering homelessness, or whether these variables have a greater chance of occurring following the manifestation of homelessness, will have implications for the development of interventions.

While substance use and mental health disorders are shown to occur at increased rates among the homeless as compared to the general population (Fazel et al., 2008), teasing out their particular relationship with the onset, life course, or outcome of homelessness may be difficult to do. In their longitudinal investigation of 344 single adults recruited from municipal homeless shelters in the New York City area, McQuistion, Gorroochurn,Hsu, andCaton (2013) sought to measure the constructs of substance use and mental health, among others, to discover what relationship they had with whether or not someone experienced chronic homelessness, recurring homelessness, or successful rehousing over an eighteen-month period. The authors hypothesized that recurrent homelessness would be associated with characteristics that limit or impede a person’s ability to function, and additionally sought to determine if these characteristics may be independently predictive of recurrent homelessness, or if they are associated with other outcomes (McQuistion et al. p. 2, 2013).

Defining the variables

The dependent variable in this report is described as the life course of experienced homelessness. The researchers limited their participants to exclusively include those who were experiencing homelessness for the first time, so as to observe differences in individual characteristics of those who go on to experience recurrent or chronic homelessness and those are rehoused. The authors recruited participants from the municipal shelter system, and relied on retrospective self-report to measure the continued progress of housing status. Interviews were conducted every six months, while brief check-in interviews were conducted monthly, in an effort to reduce recall bias. As the study proceeded, the authors divided participants into one of three categories: (1.) those experiencing recurrent homelessness – one or more further lapses of homelessness following rehousing, (2.) chronic homelessness – the absence of any housing following baseline interview, and (3.) stably housed – the acquisition and successful retaining of fixed permanent dwelling (McQuistion et al. p. 3, 2013). As a dependent variable, life course of homelessness in this study is sufficiently nuanced to include a wide range of possible experiential outcomes over a span of time, but the concept of “homelessness” itself is narrowed by the restraints of the study’s recruitment technique. While drawing their entire recruitment pool from the municipal shelter system of New York City ensured that participants were experiencing true homelessness (McQuistion et al. p. 2, 2013), this definition of homelessness still excludes those who may be sleeping in cars, residing in homeless encampments, occupying public spaces, or otherwise absent from the shelter system. There will be no way to say whether the results obtained in this study would be any different for people who may not utilize shelters upon entering homelessness.

The independent variables in this study are described as “risk variables” (McQuistion et al., p. 3, 2013), demographic characteristics, and personal history information. The authors describe only a few of the instruments that were used in gathering this information. Upon initiating the baseline interviews, participants were screened for criteria of DSM-IV Axis I disorders (including substance abuse disorders). The Structured Clinical Interview for DSM-IV was used for this purpose, for the sake of brevity. The only Axis II diagnosis screened was antisocial personality disorder, because it is the only Axis II disorder in which behavioral history is the primary criteria (McQuistion et al. p. 2, 2013). While this may be convenient, excluding the diagnosis of other personality disorders further limits the generalizability of this data. History of living arrangement, education, income, employment history, criminal justice involvement, history of childhood placement, and current familial support were also obtained (McQuistion et al,. 2013).

“Out-of-home placement” in childhood was defined as residing with a non-relative before the age of 18 (McQuistion et al., p. 3, 2013). Once again, the definition of this construct may be too narrow in scope, as it overlooks those who have had a similar “out-of-home placement” experiences, but have been placed with distant relatives through foster care. Familial disorganization during childhood was assessed by asking a series of questions related to parental substance abuse, parental criminality, family violence, and other similar items. According to the authors, “family disorganization” as a construct had a reliability ? coefficient of .71 (McQuistion et al. p. 3, 2013). Other reliability coefficients for the remaining instruments were not disclosed.

Relationship between variables

Following data collection after eighteen months, cases were divided into the aforementioned three categories of homeless life course (McQuistion et al. p. 3, 2013). The authors then used multinomial logistic regression analysis to investigate the relationship between each of the housing categories and the risk variables, while controlling for demographic characteristics (McQuistion et al. p. 6, 2013). Some noteworthy associations were discovered.

On its own, substance abuse was associated with increased rates of recurrent homelessness when examined in a bivariate analysis (McQuistion et al. p. 8, 2013). Among the risk variables and dependent variables, no isolated variable was statistically significantly associated with housing status outcome following multinomial logistic regression analysis. However, the authors point out that upon combining three factors – (1.) substance abuse within 30 days prior to baseline interview, (2.) history of arrest, and (3.) a diagnosis of antisocial personality disorder – an outcome of recurrent homelessness could be exclusively predicted. These findings suggest that while no single variable may predict the life course of homelessness, a grouping of risk factors may increase the likelihood of one outcome over another. There are associations, particularly between substance use and the homeless life course, but they may not reach critical influence unless they occur in conjunction with other factors. These findings further illustrate the idea that the phenomenon of homelessness is complex, hard to explain, and involves the culmination of many forces (McQuistion et al., 2013).

Discussion – internal validity

The internal validity at issue in this study comes down to establishing the relationship between three statistically significant risk factors and an outcome of recurrent homelessness, specifically whether one causes the other. While the authors took steps to safeguard against the threat of confounding and selection bias by virtue of the potential independent variables they accounted and controlled for, there are still issues with establishing internal validity. Although the three variables that were collectively linked with recurrent homelessness were temporally established as preceding the outcome, there are alternative explanations for this. Arrest history and antisocial personality disorder have historically been closely related (Hodgins, & Cote, 1993; McCabe et al., 2012). That these both occurred together is redundant, and suggests that one variable that could have covered both of these simultaneously had to be divided to produce the appearance of a significant association. Furthermore, the authors describe a substance use disorder within the past thirty days of the baseline interview as being the third predictive variable for recurrent homelessness. That reported substance abuse was present prior to the baseline interview – and subsequently the first of many recurrent homeless episodes – throws doubt on the temporal assumption of one variable causing the other. Participants could have forseen their entry into homelessness as their support networks fell apart, began using a substance to cope, entered homelessness, and continued using. In this case, entry into homelessness may have brought on substance use, rather than the alternative. That there exists this alternative explanation casts doubt on the internal validity of asserting cause-and-effect between this article’s dependent and independent variables.

While this article does contribute to our understanding of the factors associated with recurrent homelessness – and may even suggest a temporal relationship – it is not flawless. Research attempting to identify the possible causes of a complex phenomenon like homelessness will undoubtedly encounter difficulties in doing so. Regardless, it is the collective contributions of these efforts that will continue to inform our knowledge base, and consequently our interventions, with this population.

References

Aubry, T., Klodawsky, F., & Coulombe, D. (2012). Comparing the housing trajectories of

different classes within a diverse homeless population. American Journal Of Community

Psychology, 49(1-2), 142-155.

Chamberlain, C., & Johnson, G. (2013). Pathways into adult homelessness. Journal Of

Sociology, 49(1), 60-77.

Fazel, S., Khosla, V., Doll, H., & Geddes, J. (2008). The prevalence of mental disorders among

the homeless in Western countries: Systematic review and meta-regression analysis.

PLoS Medicine 5(12), 0001–0012.

Hodgins, S., & Cote, G. (1993). Major mental disorder and antisocial personality disorder: A

criminal combination. Bulletin Of The American Academy Of Psychiatry & The Law,

21(2), 155-160.

Johnson, T. P., Freels, S. A., Parsons, J. A., & Vangeest, J. B. (1997). Substance Abuse and

homelessness: Social selection or adaptation. Addiction, 92, 437–445.

McCabe, P. J., Christopher, P. P., Druhn, N., Roy-Bujnowski, K. M., Grudzinskas, A. r., &

Fisher, W. H. (2012). Arrest types and co-occurring disorders in persons with

schizophrenia or related psychoses. The Journal Of Behavioral Health Services &

Research, 39(3), 271-284.

McQuistion, H. L., Gorroochurn, P., Hsu, E., & Caton, C. M. (2013). Risk factors associated

with recurrent homelessness after a first homeless episode. Community Mental Health Journal, doi:10.1007/s10597-013-9608-4

1

Cheniere Energy was founded in 1983 and is a world leading liquefied natural gas (LNG) company. Through its subsidiaries the company engages in the development, construction, ownership, and operation of onshore LNG receiving terminals and natural gas pipelines in the Gulf Coast of the United States. It also engages in oil and natural gas exploration and development activities. Cheniere Energy is based in Houston, Texas with offices in Johnson Bayou, Louisiana, and London – called Cheniere International UK Branch. The London office consists of six people who are responsible for sourcing and trading LNG cargoes for Cheniere as well as managing the day to day operations and activities of the office.

Purpose of the report

The purpose of this report is to examine work issues at Cheniere International UK Branch resulting from office harassment and specifically the conflict between an office assistant and the operations manager. It focuses on the interactive behaviour themes relating to communication, work relationships and leadership.

Definition of Interactive Behaviour at work

The term interactive behaviour at work refers to the reciprocal communication conduct of two or more persons. It covers both their overt behaviour and the factors and processes underlying it. It also extends to the use of communication for purposes such as self-presentation, co-operation, influencing others, working in groups and leadership. (Guirdham, 2002)

Definition of the themes
Communication

According to Guirdham (2002) communication is a process of transferring information from one entity to another. Interpersonal communication at work may be face-to-face or indirect, formal or informal, and transmitted verbally or non-verbally. Communication is affected by language, communicator style, the differences between one- and two-way communication, power and status, culture, gender and disability. These effects on communication give rise to barriers, which can be analyzed as intrinsic, individual level and inter-group. To be high in quality, communication must overcome these barriers.

Work relationship

Interdependence and social orientations, roles, norms and conformity as well as co-operative, competitive and conflict behaviour are all concepts that help us to understand and be more effective in work relationships. Other important aspects related to the issues discussed cover conflict resolution, cultural differences, coping with prejudice, discrimination and harassment. (Guirdham, 2002) Harassment is defined as: conduct which is unreasonable, unwelcome and offensive, and which creates an intimidating, hostile or humiliating working environment. (Mullins, 2005) Harassment is a potential cause of stress. The Health and Safety Executive (HSE) defines stress as: “The adverse reaction people have to excess pressure. It is not disease. But if stress is intense and goes on for some time, it can lead to a mental and physical ill health”.

Leadership

Leadership can be defined as “the ability of an individual to influence, motivate and enable others to contribute towards the effectiveness and success of the organisation of which they are members” (Guirdham, 2002) There is a close relationship between leadership and management, especially in work organisation, and an increasing tendency to see them as synonymous. However, arguably there are differences between the two and it does not follow that every leader is a manager. Leadership might be viewed in more general terms, with emphasis on interpersonal behaviour in a broader context. According to Mullins (2005) due to its complex nature there are many alternative ways of analysing leadership. Leadership may be examined in terms of qualities or traits approach, in terms of the functional or group approach, as a behavioural category, in terms of styles of leadership, through the situational approach and contingency models, and in terms of distinction between transactional and transformational leadership.

Problem identification

The issue discussed in this report involves the deteriorating relationship between a manager and an assistant (myself) in a small office environment. In addition the report looks at the behaviour of a director of the company involved to whom the employees were directly responsible to.

Matters discussed include the identification of key points of conflict between the two persons involved, the style of management, the reaction of fellow employees, the interaction with the director involved and steps taken to resolve the issue.

Background and causes of problems

I joined the Cheniere International UK Branch in 2008 as an office assistant. Working at their London office in Mayfair where there were three other employees at my level, two were English and one was an American. I was the only one having English as a second language.

The operations manager was a mature English lady with a very strong personality and an accretive attitude. I noticed that I was being asked to do considerably more work than the other assistants and that the manager was querying my efforts every day. At first I thought this was because I was new to the job and that it was a way of measuring my capabilities and ability to cope with the stresses of the work. It became clear however that this was much more of a particular attitude toward me as compared to the other employees.

Maybe write something about working in a multi-cultural environment or possibly highlight that there was predominance of white Anglo-Saxon employees and as such no exposure to different cultures or ethnic diversity.

Inter-cultural problems arise when members of an in-group perceive members of an out-group as inferior. This can promote in-group favouritism, increased tendency to stereotype members of out-groups and negative attitudes to actual or perceived cultural differences. It can result in exclusion of members of out-groups, negative evaluations and harassment.

In a small office environment it would be unusual for someone in a position of authority to feel threatened by a single junior employee.

It is difficult to give any clear instances of harassment, as such, as this was a subtle but constant undermining of my position on a daily basis. This was apparent in her constant criticism of my work and references to my Polish background and English not being my native language. I made a point of asking the other assistants to check my work and they always said it was fine and that was just “her way” and not to worry. One occurrence that began to give me an insight to her behaviour was when she asked me, in front of all the other assistants, why “I did not work as a nanny or cleaner as all other Polish girls did”.

This indicated to me that there was the possibility that her actions were not actually based upon my performance but upon a much deeper prejudice and possible stereotyping of Polish people (either collectively or by gender).

In a strange way this was a relief as until then my confidence had been undermined and I felt under stress at work. It seemed nothing I ever did was right, I was often depressed, both at work and at home and it was difficult to understand why she picked on me and what was causing the problem. It also made it difficult for me to try to see how I could resolve the problem.

Being aware of the personality clash between us I was trying to understand what caused her hostile behaviour and I blamed myself that it was I who caused the conflict, but on the other hand I knew I normally never have any major problems engaging with people, being an easygoing and friendly person. The Thoms-Kilmann Conflict Mode Questionnaire can be useful in explaining my stance in the conflict. Scoring 9 in avoiding and 9 in accommodating styles shows that I am not an assertive person, do not wish to hurt people’s feelings, obey orders and I am generally a selfless type of person. (See Appendix x for a copy of the Thoms-Kilmann Conflict Mode Questionnaire you took.)

It was very difficult to please and satisfy her probably because she developed irrational beliefs and prejudiced views about me. If being from Poland meant to her that I should be a nanny or cleaner she maybe believed that people of other races or backgrounds are in some way inferior and therefore deserve to be treated as second class. According to Tehrani (1996) the lack of self awareness in harassers increases their fears and prejudice. Harassers never feel strong enough to test their views objectively, preferring to live in an irrational world, where they need to continually support their prejudiced views with biased evidence. To explain even deeper her behavior I would say she portrayed the actions of a stigmatizer.

Freidson (1983) stated that in Erving Goffman’s theory of social stigma “a stigma is an attribute, behaviour, or reputation which is socially discrediting in a particular way: it causes an individual to be mentally classified by others in an undesirable, rejected stereotype rather than in an accepted, normal one”. In this manager’s eyes I was different; she may not want to accept me because of my nationality, my different accent, my origin.

Goffman divides the individual’s relation to a stigma into three categories: the stigmatized are those who bear the stigma; the normals are those who do not bear the stigma; and the wise are those among the normals who are accepted by the stigmatized as “wise” to their condition. I then represent a stigmatized person, the manager is normal and rest of our team can be seen as wise.

Strategic Implications of the problem

My case can be seen as a micro problem because it describes a situation in a small office and only a few people are involved in the conflict. I am the only person who was harmed and it could be argued that it is difficult to show macro implications from this issue. However, I would like to stress that harassment at the workplace occurs very often and causes a lot of problems. According to the Advisory, Conciliation and Arbitration Service (ACAS) harassment in the workplace costs employers in the UK more than ?2bn per year in sick pay, staff turnover and lower productivity. 19 million working days are lost each year as a direct result of workplace harassment. 1 in 4 people report that they have experienced harassment in the last 5 years. 70% of HR professionals have witnessed or have been aware of harassment in their organisation. Organisations that fail to address the problem of unacceptable behaviour at workplace pay a heavy cost in terms of loss of staff, reduced innovation, morale and sickness absence. This is in addition to the cost of litigation and bad public relations (Tehrani, 1996). My issue did not affect the organisation in a significant way, except high staff retention – within 1 year two office assistants left the company because of Jane’s difficult character.

As mentioned before 25% of the population suffer from harassment. By describing my personal experience I raise an issue that affects a lot of people and something that organizations have to deal with. Harassment is related with work relationship – one of the main themes which are described in this paper. According to Tehrani (1996) harassment has a number of common elements; it involves a hurtful behaviour, this behaviour is repeated over a period of time and the person being harassed finds it difficult to defend themselves. People being harassed will also have difficulty in being rational in their thinking, believing the acts or views of a harasser are the views of everyone else. When I was working for Cheniere I was felling sad, negative and worthless. In addition my feelings were heightened with outbursts of anger, crying, loneliness and hurt. Lack of pleasure in almost everything that I was doing was significant and difficult to cope with. Being humiliated resulted in the lack of self confidence to assert myself and challenge the unacceptable behaviour of operations manager. It needs to be added that harassment is linked with stress. Guirdham (2002) stated: “Some of the major effects of stress include sleep trouble, tiredness, being unable to cope well in conflict situations, wanting to be left alone, smoking, drinking and eating too much, being unable to influence or persuade people and finding it difficult to get up in the mornings”. I recall that I was often very tired, could not sleep, and did not want to see my friends or family.

Some people were asking me why I let her be abusive and rude towards me. The answer is – because she had power over me. As I mentioned I held the lowest position in the office and I was supposed to listen to everyone and doing whatever they needed at work. Among French and Raven’s (1959) power sources there is one which can be implemented in this situation – coercive power. (Podsakoff and Schriesheim, 1985) Threats and punishment are common tools of coercion. I was often given undesirable tasks by Jane. There is one in particular where she spilled tea on her desk and asked me to clean it. My example demonstrates that this source of power can often lead to problems and in many circumstances it involves abuse. Coercive power can cause unhealthy behaviour and dissatisfaction in the workplace. (mindtools.com)

From my above evaluation it can be stated that the operations manager was definitely my significant other at that time. She had very strong influence on my self-esteem and my behaviour.

Many organisations and their managers and executives are guilty of ignoring, tolerating or sustaining conflicts and harassment (Guirdham, 2002). This statement confirms the behaviour of my director who was trying to explain me that I should accept the fact that Jane is generally a difficult person and therefore should not take it personally what she says and how she behaves. Lack of leadership qualities can be seen in my boss’s attitude. A large portion of the existing literature on leadership focuses only on the positive traits of leaders. However, the so-called “dark side of leadership”, or negative personal traits of leaders, has received relatively less attention. Also, in practice, leadership is mostly evaluated in terms of the positive traits and strengths of leaders, even though certain organizational factors and followers’ characteristics significantly contribute to the effectiveness or ineffectiveness of leaders (Toor and Ogunlana, 2009). The director was not an effective leader. A leader who lacks character or integrity will not be seen as a competent one. Even though he was intelligent, affable, persuasive, or savvy, he was also prone to rationalizing unethical behaviour. Office harassment is a very unethical issue and should be resolved by a company’s leader, but it was not in my case. Moreover leaders not attuned to the needs of the employees are not effective either. Successful leaders focus on workers satisfaction and loyalty. They should find ways to consistently engage them and incorporate them into company’s policies and make sure they know and obey their code of conduct. If they ignore, mistreat, or otherwise do not value their employees, they will not be valued for competences. Furthermore good leaders should communicate effectively across mediums, constituencies, environments of course employees. My boss was aware that Jane’s behavior was harmful but did not react and did not want to be involved in the conflict. This observation can lead to a statement that the director represented a laissez faire leadership style. According to Flynn (2009) this type of a leader describes passive leaders who are reluctant to influence subordinates or give direction. They generally refrain from participating in group or individual decision making and to a large extent, abdicate their leadership role. Subordinates are given considerable freedom of action and, therefore, seem likely to maximize their power and influence. Although laissez- faire leadership can be very successful in some environments where followers are responsible for self-monitoring, problem solving in my case it was not what I needed. I was looking for a mediator in my conflict with Jane, someone who can direct and take steps to resolve the problem. From Blake Mouton Managerial Grid perspective, it could be argued that the director represented Impoverished Leadership which is known for creating a work environment that is not satisfying and not motivating. The result is a place of disorganization, dissatisfaction and disharmony. (Rollinson, 2005) My boss had low concern for employee satisfaction because knowing I was depressed and was in a conflict he was not concerned about it.

A major danger of stereotyping is that it can block out accurate perception of an individual and lead to potential situation of prejudice or discrimination. This in consequence can build communication barriers. Jane’s tendency to ascribe negative characteristics to me on the basis of a general categorisation was a simplified process of her perception. Her stereotyping process based on my nationality and education had a significant implication to the atmosphere in our office and my wellbeing. Her prejudice caused communication problem between us. According to Erven (2008) stereotyping is a barrier to communication when it causes people to act as if they already know the message that is coming from the sender or worse, as if no message is necessary because “everybody already knows.”

People stereotype genders, races, religions, and cultures. They combine them to say things but often incorrectly creating assumptions. Stereotypes develop from reality. “Poles steal British jobs” became a stereotype because a lot of Poles are poor and had to learn how to survive and came here to look for a job but they do not deserve to be stereotyped. It might be true that most of Polish women work as nannies or cleaners but, it does not identify me, my needs, and my weaknesses. So if Jane used the stereotypical view of Polish women towards me, she missed who I actually am, as an individual. I wanted to communicate, talk to her and did not want to be lost in the stereotypical concept. People are complex and need to be understood as individuals, not stereotypes. Uniqueness is what gets lost in the stereotypes and lack of proper communication. People should listen, understand, consider the whole person, and that requires rejecting the preconceived assumptions, based on the stereotypes that are created and used.

Communication is at the heart of many interpersonal problems faced by employers.

Understanding the communication process and then working at improvement provide a recipe for becoming more effective communicators. Knowing the common barriers to communication is the first step to minimizing their impact. Stereotyping is a barrier to proper communication, it cannot just disrupt communication, it can destroy it.

The significance of non-verbal communication and body language need to be evaluated in this report as in my case it was more important than verbal communication. According to Mullins (2005) non-verbal communication includes inferences drawn from posture, gesture, touch, invasion of personal space, extent of eye contact, tone of voice or facial expression. Very often the operations manger was using proper language and if was not obvious for others to see the conflict between us and her antipathy.

Her tone of voice and facial expression were sending messages that I was not accepted and were unwelcomed. Mullins (2005) adds also that in our face-to face communication with other people the messages about our feelings and attitudes come only 7 per cent from the words we use, 38 per cent from our voice and 55 per cent from body language, including facial expression. Significantly, when body language such as gestures and tone of voice conflicts with the words, greater emphasis is likely to be placed on the non-verbal message. He also suggests that when verbal and non-verbal messages are in conflict (like in my case regarding communication with the operations manager) accepted wisdom is that the non-verbal signals should be the ones to rely on, and that what is not said is frequently louder than what is said, revealing attitudes and feelings in a way words cannot express.

Alternative options for resolving problem

Leave the job or stay.

People have bad days at work. But if that bad day is every day, it might be time to consider leaving the job. Some causes of job dissatisfaction are impossible to alter, and in this case employees may well be better off making an exit. Leaving the job is usually a very difficult decision and can often cause mixed emotions: joy because of moving on to something better, sadness at losing people we enjoyed work with, relief we don’t have to cope with the problem and conflicts anymore. Uncertainty about the future and new job has usually a big impact on people’s decisions. I was also concerned about my future.

Staying with Cheniere was an alternative, but I was concerned how I can change the atmosphere and Jane’s behaviour. Talking to her or to my boss were the options to make my work conditions better. Alternatively I could stay with the company and try to accept the environment and ambiance, and try to reduce sensitivity to hostility or displays of prejudice. Mullins (2005) evaluated difficult people: “Perhaps our reluctance to identify, and then directly address, conflict within organisations is based upon the widely held belief that conflict is inevitable, negative and unmanageable”. There is a tendency to see conflict as a result one person’s personality. Conflict may be inevitable, but how dramatically situations could be changed if we could also view it as positive and manageable. What if we think of these situations as raising questions of difference? What if we were to make a shift away from blaming individuals and their personalities, recognizing instead that it is through normal human interaction that outward expressions of difference are produced? Unfortunately coping with difficult people is not one of my strong points.

Another option was to beat her at her own game. Act like her, be unsympathetic, telling colleagues how unfair she is. This option would be very difficult because she held higher position and therefore had power and because I respect people it wound be something against my values and beliefs.

Choice of option

I was trying to resolve the problem. I talked to the director but was ignored and was told that I should accept the situation as it is and accept Jane’s behaviour because she is difficult and she is not going to change her attitude. Another advice was that I should be less emotional and try to be mentally stronger. He did not wish to speak to Jane to ask to change her attitude and help her to cope with her hostile behaviour. Tehrani (1996) argue that the role of leader in developing the skills which enable people to communicate in an open and assertive manner is perhaps one of the most effective tools in addressing conflicts. The support of an assertive and caring manager is an important aspect of rehabilitating a harasser. Harassers need support when they are developing the new skills and behaviors in communication which will replace the harassing behaviours. I also talked to Jane but I was told that I read her intentions badly. She was trying to tell me that there was no issue between us and I should not waste her time for such conversations.

Rationale for choice

Because I had an interesting job, was satisfied with my compensation I did not want to leave thus I was trying to find a resolution. I was not accepted by one of the co-workers but I did not want to be a victim of harassment. I was trying to be a survivor. According to Tehrani (1996) victims of harassment frequently express the view that there is little they can do to prevent the harassment taking place. They have no choice but to put up with what is being done to them. This perception of lack of personal control or power must be changed if the harassee is ever to make sense of what has happened to them. Survivors, on the other hand, are able to begin to make choices and decisions about what they want to do to stop or resolve the harassment. Survivors of harassment take an active part in deciding how they would like things to be handled when resolving their problems. They are keen to take responsibility for making things happen, rather than behaving passively, allowing others, however well meaning, to take over control. One of the main skills survivors of harassment learn is to be assertive in expressing what they want and do not want to happen during the harassment investigation; to be able to say yes or no regardless of the wishes of others. Assertiveness is also one of the most important skills needed to prevent harassees becoming victims of harassment in the future. Finally the survivors of harassment are able to look forward to the future, a future without harassment, while the victims concentrate on the harassment itself, rather than on how they can change things to prevent the harassment occurring again. Although I was trying to help myself, was looking for help from the directors and also arranged a meeting with Jane, nothing changed.

Implementation of Option

I eventually decided to leave. It took me 2 weeks to find another job. The difference in the working environment was immense. New co-workers were pleasant and friendly. I am glad that I took control over the situation and left the company. I will never fully forget this experience but sometimes we should experience and accept the extremes, because if the contrast is lost, we lose appreciation.

Time for Implementation

I was working for this company for 5 months before handing in my resignation.

Conclusion

In recent years there has been an increasing recognition of the harm that could be done to individuals who become the victims of harassment or bullying. Although there have been significant moves to introduce legislation and guidelines that deal with the introduction of organizational policy and procedures on harassment and bullying, the occurrence of harassment is still common in many British organizations. My case in this paper can be perceived as a representation of this problem for many organizations. This is not an easy issue to deal with for mangers, people who cause harassment and most of all for people who suffer from hostile behavior. Background and causes of such conflicts are often implicit and not easy to resolve. Understanding the communication process and communication barriers is important to effectively control the problem. Leadership skills and appropriate use of power can be crucial.

Introduce ICCMW Services in Hong Kong

Integrated Services in Hong Kong

Start from 1991, the establishment of first integrated youth services centre, there are more and more integrated services has been developed in Hong Kong. It is believed that integrated services generated a lot of advantages, such as avoiding wastage of resources and duplication of services. For different target group of people, different kind of integrated services has been developed afterwards. Nowadays, there are integrated youth services (ICYSC), integrated family services (IFSC), integrated elderly services (DECC), integrated disable services (DSC), and integrated mental wellness services (ICCMW) in Hong Kong. In this paper, the integrated services of mental wellness in Hong Kong will be focused and discussed. The strengths and limitations of this integrated social service would be analysed, as well as the improvement of implementation.

Background of Integrated Mental Wellness Services

In March 2009, Social Welfare Department set up the first Integrated Community Centre for Mental Wellness (ICCMW) in Tin Shui Wai. The major aims of setting up ICCMW are enhancing the social support and re-integrating the ex-mentally ill persons into the community (Social Welfare Department, 2014). The goals of ICCMW are providing one stop services and accessible community supports for the needy. The targeted service users are discharged mental patients, persons with suspected mental health problems, their families or carers of above persons, and people who are interested in understanding and improving their mental health. ICCMW has been established in all the 18 districts in October 2010. Upon now, there are 24 ICCMW provided by 11 non-governmental organization (Social Welfare Department, 2014).

Integration of Services

Generally, there are three integration levels that integrated services have to address the different needs of clients, includes ICCMW, which are linkage, coordination, and full integration. For the first level, linkage, ICCMW would like to link up the service users and the particular services. For example, it provides information for people who concern about their stress level. For the second level, coordination, ICCMW would serve the function of coordinator between systems and agencies, process to address problem of service users. For example, follow up the case which just has been discharged from hospital by providing day training programs or counseling services in the centre or in other organizations, is a kind of cross-sectional operation between medical and mental wellness sectors. For the third level of integration, full integration, multidisciplinary team cooperation, and community integration would be the targets of ICCMW. There are nurses, occupational therapists, doctors, clinical psychiatrists, social workers as a team to provide mental rehabilitation services for clients, in order to let clients re-integrated to the community.

Using the agency of The Wellness Centre in Tin Shui Wai of New Life Psychiatric Rehabilitation Association (New Life) as an example, it provides prevention services and intervention by using recovery-oriented approach. For the prevention, New Life offers a lot of mental health promotions and public education, letting general people have more understanding about mental health and mental illness. For the group work intervention, New Life provides support groups, carer volunteer training, and psycho-education programs for clients. For the individual level intervention, New Life provides counselling, peer support worker training, vocational planning and development services, wellness programs, and so on (New Life Psychiatric Rehabilitation Association, 2013). These kinds of intervention and therapy are for the goal of making people with mental health problem to reintegrate to community.

Strengths of ICCMW

There are a lot of advantages of setting up integrated services in Hong Kong, so do ICCMW. The first advantage of ICCMW is, convenient to services users. For the service users, ICCMW is multi-functional which provides occupational training, vocational training, care and support, and leisure opportunities. For the public who concern about their mental wellness, they can self approach ICCMW and ask for information and related services. Services are easier accessed nowadays.

The second advantage of ICCMW is better coordination among workers and services. After integration, there are multidisciplinary within a team in ICCMW, such as occupational therapist, nurses, doctors, and social workers. They have regular case meetings for discussing how to manage the case, and it is believed that coordination would be better between each division due to more communication.

The third advantage of ICCMW is reducing stigmatisation. ICCMW provides different kind of services, not only giving therapy and counselling for people with mental illness but also providing public education and volunteer trainings for mentally ill person or the caregivers. Public education serves the function of letting general public know more about mental health, and letting them to understand that it is not only refer to mental illness but also mental wellness related to everyone. Also, the chance of letting mentally ill person doing voluntary work to community helps them integrating back to community. Therefore, multidimensional services provided by ICCMW would let the concept of mental health and also the mentally ill person integrated into community.

Limitations of ICCMW

A coin has two sides, although ICCMW provides lot of advantages to service users and community, it is not faces no limitations.

Firstly, ICCMW is hard to select centre location. Usually, ICCMW have to select a location for services centre which is close to community for residents convenience, however, there are lots of limitation of setting up centre in estates. Many of the ICCMW reflects that they are hard to find a permanent premises which are large enough for group services and training. And the reason may attribute to the approval time of Welfare Department are too long (Cheung, 2011). In addition, there are objective sounds reject if ICCMW is too close to community or located in estate. For example, in 2010, the residents and the district councilor of Tuen Mun Wu King Estate objected one ICCMW established in their estate, and requested the moving out of ICCMW (MingPao Health, 2011). The major reason is due to stigmatization of mentally ill people who are dangerous and would attack public suddenly. Therefore, residents object if ICCMW too close to the residents.

Secondly, there is shortage of man-power. As integrated, ICCMW needs professional staff from different discipline such as nurses, clinical psychiatrists, and doctors. It is all known that, these kinds of professions are now shortage in Hong Kong. Even an ICCMW start in estate, they may face the problem of down man-power for a period of time.

Thirdly, it is time-consuming to have meetings for multidiscipline to discuss and examine the case management. Since services integrated, operation complexity would be increased. Regular meeting is essential to understand the roles and views of other professions, however, caseworks and pressures would relatively increase. That makes the workers may easily burnt out for the increased duties.

Lastly, there is lack of centralized data for different agencies. Although the communication and interaction between agencies, departments, or bureaus increased under integrated services, they do not have share information between each other. For example, a mental illness patient who just discharged from hospital with marriage problem, Medical Social Services Department in Hospital, Integrated Family Service Center (IFSC), and ICCMW would be involved in this case. Since there are no platforms for information sharing between agencies, the social workers in ICCMW may need to contact IFSC social workers and medical social workers particularly for further information. Procedures may be duplicated due to lack of data transparency.

Suggestions for ICCMW

First of all, it is suggested that increase the linkage between agencies and organization by developing a platform to share essential information. For example, the doctors in hospital can provide medical reports, integrated progress notes provided by social workers from related agencies etc. It is believed that can raise the transparency of information and data.

In addition, it is suggested that Social Welfare Department can simplify the application system of centre location, to avoid the situation that appropriate venue has been rented by other private parties during the long and complicated approval process.

Furthermore, it is important to strengthen the public education for public understanding the nature and image of ICCMW. As residents have misunderstanding about people with mental health problem are all dangerous to society, public education is necessary to eliminate their incorrect perception. It is recommended that government should strengthen the advertisement and civil education in community and education institutions, to let people have correct concept about recovered mental ill person that they are also a part of society, and not only harmful to society.

Finally, it is also suggested that more resources should be granted for ICCMW. As ICCMW is the newest service within integrated services since 2009, the resources and experiences are not yet well-developed. Therefore, resources like funding for ICCMW allow them to purchase more useful treatment tools for clients, or hire more professional staff for relieving the pressure of existing staff.

Conclusion

Integration of services in Hong Kong are designed to fulfill different needs of clients, and avoiding wastage of resources. ICCMW generates the advantages of convenience to service users, better cooperation among services workers, and reduce the stigmatization of mentally ill people in society. However, there are still some limitations that ICCMW facing, such as difficulty of selecting centre location, shortage of man-power, time consuming of multidisciplinary meeting, and lack of centralized data. It is believed that ICCMW is still in the developing process, if government provides certain assistances and recourses for them, the integrated services would benefit more and more people in need in the coming future.

References

Cheung, K. C. (2011), Hong Kong Social Workers General Union. Service Series- Rehabilitation Services, Retrieved on 29 April 2014 from http://www.hkswgu.org.hk/node/70

MingPao Health (2011), “Only 6 out of 24 ICCMW location confirmed” retrieved on 5 May 2014, from http://www.mingpaohealth.com/cfm/news3.cfm?File=20110213/news/gok1.txt

New Life Psychiatric Rehabilitation Association (2013), Annual Report 2012-2013. Retrieved on 2 May 2014, from http://www.nlpra.org.hk/information_n_publications/Annual_report/pdf/049_117_2013.aspx

Social Welfare Department (2014), Integrated Community Centre for Mental Wellness (ICCMW), Services Description, retrieved on 2 May 2014, from http://www.swd.gov.hk/en/index/site_pubsvc/page_rehab/sub_listofserv/id_iccmw/

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