Risks, rights, values and ethics

[Introduction]

The Research in Practice for Adults podcast, supporting evidence-informed practice with adults and families.

Lisa: Hello, and welcome to this RiPfA [Research in Practice for Adults] podcast on risks, rights, values and ethics. I'm Lisa Smith, I'm the Assistant Director of RiPfA and I'm here with Lydia Guthrie who's recently written our latest frontline briefing, risks, rights, values and ethics. Hello, Lydia.

Lydia: Hi there, Lisa. Hi, my name's Lydia Guthrie, as Lisa just said. Just a little bit of information about myself in case you're curious, I qualified as a social worker and then went into the probation service where I worked as a practitioner and as a manager. I left the probation service in 2009 and since then, I've worked independently as a trainer, I also offer supervision and I write things and I'm delighted to be a RiPfA associate. I'm also in training as a family therapist and I have a real interest in supervision and in relationship-based practice.

[Risk analysis]

Lisa: We're going to have a bit of a conversation today around, kind of, risks, rights, values and ethics and, kind of, what we bring to our practice and thinking particularly around that area of risk. In thinking about that for RiPfA in our delivery programme, we wanted to build on, sort of, the work that we've done before that's been around very much risk enablement and, kind of, take it a step on, so thinking about, kind of, the stuff that we bring as individuals, as human beings. Did you want to say anything more about that, Lydia?

Lydia: Thanks, Lisa. Yes, so when we were first discussing this frontline briefing, one of the issues that really struck us was that whenever social workers or other social care professionals are involved in helping people to make decisions or supporting people to make decisions, there are always issues of moral complexity. Sometimes we have a myth that risk assessment or risk management can be a very scientific, very rational, logical process based on analysing all the risks, putting them in a computer and coming up with the perfect solution. But, actually, anybody who's worked in social care knows that that's a really inaccurate and oversimplified picture and not even a desirable one. So, whenever we're working with people to support them to achieve their goals and live a meaningful life that has value to them, then it's very, very likely that there will be issues of moral complexity, kind of, maybe supporting people to do things that might involve a possibility of a negative outcome but trading that off because there's a bigger possibility of them gaining something that's really important to them. I guess, what we really wanted to help practitioners to think about was how to have a framework for reflecting on the processes which occur within us as professionals when we're working with the adults who we are supporting to make decisions, often in really difficult situations.

Lisa: So, that's really interesting that you were, kind of, saying that and I suppose when I'm thinking about people working with risk and I think that, you know, if my individual tolerance of risk in my own life is relatively low and maybe I'm naturally risk-averse, does that play out in my interactions as a practitioner? Do I, you know, operate differently from maybe the next person who's less risk-averse and maybe takes more risks in their own life and I'm, kind of, interested in that as a bit of a working hypothesis, perhaps.

Lydia: Yes, I think there's definitely some value in thinking about that. As people, as human beings in our own rights, as practitioners, what is our personal attitude to risk? There might be a tendency for us to be more or less risk-averse ourselves in general terms but it's also really likely to vary between different themes. So, somebody might be very risk-averse in their own life in relation to financial decisions but might be much more comfortable taking physical risks, so bungee jumping or parachute jumping or something like that. So, I don't think it's an either-or, a binary thing, it might really vary between different decisions and it might also be really affected by our own personal, ethical, spiritual, or religious frameworks. There was a recent RiPfA briefing about supporting adults with learning disabilities to develop positive sexual relationships and one of the really interesting points I read in that briefing was that there's good evidence that if people want to develop same-sex relationships, there are many more obstacles for them in terms of being supported by professionals than if they want to develop a heterosexual relationship. Some of that might be about practitioners' own uncertainty or hesitancy or lack of confidence around issues to do with supporting people in homosexual relationships. Some of it might also be to do with homophobia, whether that's conscious or unconscious, not just in individuals but also within societal structures as well. So, it's likely to be really different, I think, on different themes.

Lisa: Yes, because one of the quotes I really, really like in the briefing, if you used that Andersen quote which talks about, 'When I talk with others, I partly talk with the others and partly with myself,' and that encapsulates the whole, kind of, really nicely and, kind of, in my conversation I'm probably talking a lot to myself. Do you want to explore that a little bit?

Lydia: Yes. I'm a big fan of that quote, it's Tom Andersen, he's a Norwegian, I think, systemic therapist, apologies if I've not got that right, Tom, and I really like this idea that whenever we are engaged in communication with another person, or in thinking about another person's situation, our own internal conversations and inner processes will also have an impact. Sometimes we have this myth around risk assessment or risk management that we can be purely logical and rational but, I think it was Beck who said, actually, “our tools to calculate risks are really rusty,” so we have this set of imperfect, rusty tools which I think is a nice idea. We kid ourselves if we think it's simple. So, it's not ever possible to separate out our personal self from our professional self, and even if it was possible, it's not necessarily desirable because we work in such a profound human arena that if we were to cut off completely from our personal selves, how would we access empathy? How would we access compassion? How would we access the relational skills and qualities that we need as social workers in order to work alongside people in a truly mutual way? So, it's not necessarily possible or desirable.

What our duty is, what our professional duty is is to become more aware of the influence of that inner conversation upon the way that we're thinking about people and the way that we're working with other people. I think there were some really nice ideas around about how we might do that. Patrick Casement who was from the Tavistock, he's the first person I came across who talked about it. He talks about having an, 'Internal supervisor,' was the phrase that he used which is an idea that we can adopt this meta position of hovering above, that we can simultaneously bear in mind two different perspectives, the perspective of the person we're working with and our own perspective, and become more aware of the interaction between those two perspectives and the conversation that goes on between them. I think in adult social care, in the briefing, those who are able to read it will see that I've added in a third element which is the organisational culture because I think, in adult social care, the voice or the drive coming from organisational culture is very, very strong. Casement was writing about psychotherapy, so it was a very different culture.

Lisa: That, kind of, echoes what Stephen Finlayson says as well, isn't it? When he's talking about risk and he, kind of, talks about risk and he, kind of, talks about who's risk is it that we're, kind of, taking care of because, actually, is it just the organisation at risk? Is everybody just operating to support and to go with their organisational culture rather than putting the person right at the middle? When we've been speaking before, you've given me this great quote about the magnetic pull of the person?

[The person at the centre of decision making]

Lydia: Yes. This is a quote that really struck me as helpful and I hope it's helpful to anybody who's listening but it came from, I think, a Court of Protection decision in 2017 involving a young man with the initials MB and MB had… there was a debate around whether or not it would be beneficial for him to move into a residential placement for 12 weeks or so, and he had expressed a very clear wish not to move into the placement. He was assessed as not having capacity to make that particular decision at that point in time but, nonetheless, the judge said that MB's own expressed goals, preferences and wishes ought to be what he termed, 'The magnetic factor', around which all other factors needed to arrange themselves. So, I really liked that kind of metaphor, that visual metaphor that the goals, wishes, preferences, value-base of the person we're supporting needs to be at the very centre and all the other factors, a bit like iron filings, you know, need to be pulled in towards that magnet and arrange themselves around it. I love that idea as a way of remembering to check with ourselves what are we putting at the centre here? Can we truly say that we've put the values, goals, wishes, identity, needs, preferences of the person we're working with at the centre as that magnetic factor? I think that can really help us in times of real uncertainty and a lack of clarity and often high emotion. I think ideas like that can really, really help to act as a check, as a bit of a compass around which we can arrange everything else and to check that we're not putting the organisation's needs at the centre because there can be a lot of pressure to do that.

Lisa: Yes. In my head, I'm envisaging it more as a, sort of, vortex that stuff is, kind of, sucking in and just making sure that the organisation doesn't pull in there in a Wizard of Oz kind of a way.

Lydia: Yes, yes. That's a nice idea.

Lisa: An organisational tornado.

Lydia: Yes, yes. I like that. Yes.

[The role of organisational culture]

Lydia: I think that also, in my mind, makes me think about a paper written by Tony Stanley, he wrote the paper based on his experience of working in Tower Hamlets, I think it was, and trying to move the adult social care much more towards a position of supporting positive risk-taking and supporting adults, moving away from the, kind of, service land or service-led provision. He writes really explicitly about the need to put ethics and values at the heart of decision making. I think it came about with the implementation of the Care Act and Making Safeguarding Personal. The idea that organisational culture needs to shift in order to support this enablement approach and positive risk-taking approach that's so outlined in the Care Act and making safeguarding personal. He talks really, really explicitly in that article about the need for the organisation to be very clear that they expect practitioners to work in this way and, crucially, we'll support them to do so.

Lisa: Yes, that, sort of, organisational stuff, kind of, really interests me and we don't have two cultures in an organisation. I remember when, it was Birmingham Children's Hospital, when they got their outstanding for CQC (Care Quality Commission), I was listening to the interview with the Clinical Director on the radio and she talked very, very clearly about the idea that you don't have two cultures within organisations. So, if they treat their staff with compassion and care as it was in that context, actually, the staff would operate in that way with the people that they were working with. It's the same if an organisation doesn't support a model, you know, excellent practice around working with risk and understanding that, then practitioners, naturally, that's not going to fall out. So, there's something about how the organisation and the cultures really support that was fundamental.

Lydia: Yes, I think that's so true. These ideas of parallel process that the way that an organisation engages with its staff is highly likely to be mirrored and to have a big impact on the way that staff engage with the families and the individuals they work with. It's a very powerful idea, I think. I think, also, we need to think about organisations' attitudes to things going wrong or to there being an outcome where there's harm. Even the phrase that I used there, 'Things going wrong,' is, kind of, interesting. I'm pulling myself up on using that phrase because if an adult is supported to take a positive risk in the full knowledge that there may be a positive outcome but there is also a likelihood of harm and the harm occurs, is that necessarily an example of something having gone wrong if the decision-making process was fully supported and done in a mindful way?

Lisa: We were doing a workshop at a conference for the Housing LIN (Housing Learning and Improvement Network) and our workshop was on working with risk and I got pulled up on exactly that because we'd put on our slides, 'And what happens when it goes wrong?' And a delegate challenged and said, 'Well, it's not that it's gone wrong,' because, actually, how embedded in us is it that working with risk is all about eliminating risk even when we're talking about risk enablement because there's a probability that that risk may occur and that doesn't mean it's gone wrong. It means that that thing has happened.

Lydia: Absolutely, yes. It doesn't necessarily mean that the decision to try it was a wrong decision because we're working with adults who have a human right to express their preferences. I can certainly think of parallels in my own life, you know, where we, in full consciousness, adopt a course of action knowing that there's a range of different outcomes. If the more undesirable outcomes occur, does that necessarily mean it was a wrong decision? Because I wouldn't have known that if I hadn't taken that course of action. I've got a slightly flat tyre on my car at the moment, so every time I get in it and decide to drive it without taking it to the garage and getting a new tyre put on, I'm consciously taking a risk that there's a possibility I'll get to my destination okay but there's also a possibility that I'll end up by the side of the road waiting for the AA (Automobile Association) to come. Other car breakdown services are available. It might still be the right decision for me to be doing that because it's a big investment of time and money to go and get the tyre fixed and the people we work alongside in adult social care have just the same right to make those kinds of calculations as everybody else without someone coming along and saying, 'You shouldn't be doing that,' or, 'You can't do that,' or, 'The fact that that thing happened is good evidence why you're not able to make those decisions for yourself anymore.'

Lydia: I think in adult social care, a discussion that we need to have is around how we support people when a negative outcome happens. There's a really nice article by a writer called Sicora from 2017 where he writes about shame, shame within social care. So, if a negative outcome occurs, often the organisation of response can be very bureaucratic. It might be a big organisational review, a bit report, that kind of thing and there are very infamous examples where those kinds of reports were really important. I'm thinking of Winterbourne View, for example, or the death of Connor Sparrowhawk in Oxfordshire, an adult with a learning disability. It's absolutely right that those kinds of negative outcomes where there was professional negligence are fully investigated and learned from but I think there's also space for a less shaming approach within organisations when there is a negative outcome. More of an acceptance that supporting people to make decisions about risk doesn't mean everybody's safe 100% of the time because that's not possible or desirable. So, when there is a harmful outcome, adopting a learning approach where we learn from it rather than blame and shame individuals and adopt more restrictive practices,

Lisa: Yes, and I think there's something there about, you know, every organisation will say it's a learning organisation. If you're, kind of, working in health and if you were applying, like, the framework of clinical governance to practice, that's one of the pillars of being a learning organisation. But, are we?

Lydia: Yes, it's a good question.

Lisa: That's a whole other podcast there.

Lydia: It is a whole other podcast. It's making me think about a really nice study that Rebecca Hawkins led in 2017 about physical mobility in older adults living in residential homes. The title is, 'If they don't use it, they lose it,' and she and her team did about 400 hours of observations in four different care homes plus some interviews with staff, and what came out of this study was a finding that the organisation's attitude to risk-taking in practice had a big impact on the extent to which the adults living in the care homes were supported to keep their independent mobility. So, for example, in one care home, the staff very actively balanced the tension between encouraging residents to remain mobile by supporting them to use whatever equipment was necessary to make their own way from their bedrooms to the dining room or the living room, wherever they wanted to go, even if it took a bit longer and even if there was a risk of falling. The reason the staff felt safe to do that and felt motivated to do that was that it came from the top. It was the very clear statement and practice of the management of that home that, 'This is how we do things here.'

But, in another care home, the staff were observed to discourage the residents from walking themselves and, instead, encouraged them to wait to be helped into a wheelchair and pushed to their destination. Of course, that, arguably, makes it less likely that somebody might fall but it also increases the likelihood that they might lose their mobility and their confidence and once lost, it's really hard to get it back. Again, in that care home, there was the same policy statement about, 'In this home, we support all our residents to maintain their mobility,' but it wasn't put into practice on the ground by managers and supervisors in the same way. So, there was a difference between the policies and the culture and I found that a really interesting example of how organisations, kind of, live their policies.

Lisa: So, those examples, are they in the briefing?

Lydia: They are, yes.

[The importance of reflection]

Lisa: They are? So, that brings us nicely back to the paper. Talking about that research, there's another really nice study that you've used in that briefing which was the Harry Ferguson work. Tell us a bit about that.

Lydia: Yes. Harry Ferguson did a study, he published a paper in 2018, and it’s open access, so hurray for that. So, anyone can access it. It's called, 'How social workers reflect in action and when and why they don't.' So, you should be able to find it, and it's set in children's services but I'm really confident that there are a lot of parallels with adults’ services about reflective processes. What Harry Ferguson and his team did was to accompany social workers on home visits to families they were working with, observe the home visits and then usually in the car on the way to the next destination or on the way back to the office, the researchers would speak with the social workers about their experience of the conversations they'd just had, asking questions about, 'Were you reflecting? What were your aims? What was it like for you?' What Harry Ferguson found was that some social workers were really reflective and were able to outline what their intention was, how they'd experienced the home visit, the thoughts and feelings that they'd had in the moment.

Other social workers found that a lot harder to put into language and to articulate to the researchers, but some social workers were also able to describe how they were limiting their reflection in order to protect themselves from really strong emotions that were arising in the moment. It's, kind of, like splitting it off and putting it in a little box because it's too much to deal with in the here and now. 'If I let that affect me, I won't be able to do my job, so I have to put it in a little box,' maybe the fear that I have or my concern for this child or my strong reaction to aspects of the home or aspects of this family's culture, whatever it might be. That, 'I'm going to put it in a little box and deal with it later.' Harry Ferguson concludes that that process can be helpful, that, kind of, splitting process to defend the self in the moment can be quite helpful and protective but it's dangerous if it becomes habitual and if the individual stops being aware that it's happening. Also, if they never go back and open the box, so it's really an argument for supporting staff, individual workers, offering them a sense of safety and containment, often through supervision, in order to open the box in a safe containing relationship to avoid psychological harm and psychological impact and to avoid them becoming too split off or two separate from the people they're working with. So, a really nice study based on observation of current social work practice and a real invitation there to all social workers, and managers as well, to consider how they use reflective process and are they sufficiently supported as individuals and as teams to open that box in a safe place.

Lisa: It's almost like all roads lead back to supervision and reflecting. Whatever the topic, they always seem to… and I do feel there's a lot to be said for that and it underpins it all.

Lydia: Yes, there is a lot to be said because of the nature of the work. I mean, in preparing this frontline briefing, I spent quite a lot of time reading court judgements and, some of them, well, all of them were profoundly moving. They all involved situations where individuals were facing oppression, facing disadvantage because of issues to do with age or disability or lack of social support, or discrimination because of some quality of themselves, race, gender, sexuality, for example, age, a mental health diagnosis and professionals don't get involved unless there are issues of potential harm, issues of potential loss. So, all of our work is hugely evocative and can raise powerful emotion, both for the people we're working with and their families, and for us as individuals, and if we don't pay sufficient attention to that, then it can have a negative impact on the way that we work. We can become too defended and think that, actually, we need strict, rational, organisational processes to somehow computerise decision making and that will protect us from this, kind of, harmful emotion stuff, or we can become overwhelmed with it and we can see high rates of burn out and high rates of negative psychological impact on staff, neither of which are good outcomes. So, I would really agree with you that we need to spend more time articulating and supporting individual practitioners and managers to articulate why there's a need for supervision and protected reflection time. It's sometimes seen as a, kind of, luxurious add on but I would argue it's absolutely critical to staying healthy in ourselves and also to continue to practice in healthy ways with the adults we're working alongside.

Lisa: That's, kind of, maybe a good note to leave this on in that practising in healthy ways, when we're able to do that then we can manage and understand, sort of, our own individual values and ethics and how they play out. Thinking, just to wrap it up and to close for people, what would our message be?

Lydia: I think in the frontline briefing, I've, kind of, proposed a model which helps us to consider the different parts of ourself. So, ourself as a professional, 'What's my professional duty here?' A huge part of which is the priority question of supporting the person you're working with to exercise their human rights and to maintain their identity and to live a life that has meaning for them. So, 'How can I maintain my professional self? Myself as a person with my own unique set of experiences and values, qualities and myself in relation to my organisation. So, my organisation's expectations of me and my organisation's processes and policies. How can I maintain a healthy balance between all those three aspects of myself? How can I have a, kind of, meta-conversation that acknowledges all three of those aspects of myself as really important?' So, I guess, that would be my encouragement to people, to have confidence in advocating for our needs as practitioners in terms of our psychological wellbeing. It's not a luxurious add on, it's an essential part of maintaining personal and professional psychological health. It isn't a nice add on. It will contribute absolutely directly to positive outcomes for the people we're working with and their families because if we as individuals are more able to articulate the challenges we face, the emotional challenges we face, we're more able to engage in a truly mutual and collaborative way, building and then using good professional relationships with the people we're working with in order to support them to live a life that has meaning for them.

Lisa: Thank you.

Lydia: Yes, thank you.

Lisa: That feels like a great place to end it. I hope people have enjoyed listening and if you can, go away and read the frontline briefing.

Lydia: Yes, and we hope that our conversion is useful to people and encouraging. I think sometimes we can feel ashamed, or that it's a bad thing to say that social work is a role that is emotionally complex as well as all the other, kind of, ranges of complexity. But, I think I would really encourage people not to be ashamed to say that and to embrace conversations with colleagues and within teams about the really complex dilemmas that we become part of in the work that we're doing.

[Outro]

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