Chapter 2 – John Byrne (D1SOP2)
Domain 1 Standard of Proficiency 2
Be able to identify the limits of their practice and know when to seek advice and additional expertise or refer to another professional.
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KEY TERMS Practice Relationship Competence Empowerment Boundary Duty of care
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Social care is … about positive change. It is using relationships to support people to achieve social justice and equality of opportunity. More importantly though, it is about compassion, kindness, and human decency. It is about selflessly using your knowledge and skills to help people to make their lives a little bit easier, while empowering them to take as much responsibility as possible for themselves. |
This proficiency is about knowledge, skills and competence. It is about knowing the boundaries of our practice and professional ability. Before we go further, it is important to have a clear understanding of what our ‘practice’ is. According to CORU (2019), social care is ‘a relationship-based approach to the purposeful planning and provision of care, protection, psychosocial support and advocacy in partnership with vulnerable individuals and groups who experience marginalisation, disadvantage or special needs’.
Relationship
In social care work, the relationship between worker and client is the foundation of everything (O’Connor et al. 2003). Its purpose is to help the client to assume as much control over their own life as possible and move toward independence. In practice, the social care worker is responsible for the development of the ‘relationship’. S/he does that in a way that is not doing something ‘to’ or ‘for’ the client, but rather in ‘partnership with’ them. Everything the worker does, involves both consciously and unconsciously, empowerment and support of the client, enabling them to take responsibility for themselves (as far as is practicable). Depending on their age and cognitive ability, for some clients that will involve decisions around fully independent living; for others, it will involve making decisions about what clothes to wear, or what food to eat.
The work is not ad hoc or informal but the product of structured assessments and interventions based on theoretical knowledge, and designed specifically to address issues of marginalisation, disadvantage and social exclusion. Irrespective of the client group, the model of practice is the same. Assessments are carried out, the client’s needs are identified and prioritised, and interventions are designed and implemented to ensure that the client’s needs are met (O’Connor et al. 2003). In keeping with the principle of empowerment, social care workers will only meet a client’s needs for them when they cannot or could not be reasonably expected to do it for themselves.
The social care worker is highly skilled in the ‘craft of care’, or the ability to notice the dynamics that play out in that relationship. S/he will typically have completed at least three years of personal development work and will have a highly tuned awareness of his/her own values, prejudices and emotional responses to people and situations. S/he will be aware of the imbalance of power in the relationship and will be trained to mitigate that by adopting emancipatory or anti-oppressive practice (Dalrymple & Burke 2006) and conveying a position of ‘unconditional positive regard’ (Byrne 2009); ‘a deeply held belief that all human beings are fundamentally equal. S/he will have a comprehensive theoretical understanding of human behaviour and social structures, and a basic training in counselling skills (Moss 2008). S/he will be adaptable to new challenges and situations and will perceive all human behaviour, no matter how bizarre it seems, as a form of communication.
The Limits of Our Practice
Knowing the limits of our skills and competencies in social care is important for several reasons, not least of which is because it is linked to our duty of care. If a worker makes a decision that is outside the realms of their professional knowledge and competence and they get it wrong, they could be in significant difficulty.
In tort (civil disagreement) law, negligence is judged by the extent to which an accused meets the standard of a reasonable person, or professional, in their care of another (Atkins et al. 2020). Where a duty of care is established and a professional could have ‘reasonably foreseen’ an issue, s/he has a legal responsibility to take action to ensure that the client comes to no harm. If the professional’s actions (or failures to act) fall below the standard of the reasonable person, or professional (and the client suffers as a direct result of those actions/omissions), the professional may be found negligent in their duty of care and be held liable for damages.
A social care worker’s personal liability for their practice is made very clear in Section 21 of the CORU Code of Professional Conduct and Ethics (SCWRB 2019), which states that workers must ‘ensure that you maintain adequate professional indemnity cover for any assessment, intervention, treatment or service you provide or have provided’. That essentially means that if you make a decision and get it wrong, you could be sued, so you must have insurance to cover the potential liability. This is further re-enforced by Section 9(f), which states that workers should ‘be able to justify any decisions you make within your scope of practice. You are always accountable for what you do, what you fail to do, and for your behaviour.’ The problem is that the scope of a social care worker’s practice is not that easy to define. A social care worker could reasonably ask: When does facilitating a client’s daily exercise become physio or occupational therapy? When does providing psychosocial support become counselling? So how do we know when our practice has gone beyond our professional competence? According to Moss (2008), all human service workers provide a level of counselling on a continuum from soft to hard. At the softer end of the scale, teachers (for example) provide emotional support to anxious students at exam time; at the harder end of the scale, psychotherapists facilitate clients to explore deep emotional trauma. The challenge for the teacher is to know where one discipline ends and the other begins. In social care, we work with a wide range of people who present with complex emotional and psychological issues, so the boundary of our practice is even more difficult to define.
Case Study 1
John is fourteen years old and lives in residential care. After a violent outburst, he becomes very upset and tells social care staff how sad he is that his dad forgot his birthday again. He explains how conflicted he feels with his dad, as he loves and hates him at the same time. Staff listen carefully, conveying compassion and empathy, but wonder if this is beyond their competence and whether it is psychosocial support or counselling.
Every day social care workers make decisions that could be considered outside the realms of their professional competence. In the above example, if the worker does not provide the space for John to explore the issue, there is no learning for him. If s/he does, then s/he could be accused of exacerbating his sadness without the competence of a professional counsellor. If the boy harmed himself or absconded after that conversation, the worker might be asked to explain why they facilitated him to explore the issue.Of course, if we were to be overly concerned with that, we would not do the work, or our practice would be so restricted that it would be ineffective. In my 28 years in social care, I have never heard of a social care worker being sued for professional negligence, so do not panic. Just remember that your responsibility is to the client, but also to yourself and to your employer. If there is any doubt that your practice decision crosses into another professional discipline, you should seek (and take) advice from a qualified professional in that discipline before developing your style of practice or proceeding with an intervention.
Case Study 2
During the violent episode, John punched a wall, sustaining a minor laceration and bruising to his hand, which caused him some pain. The staff member was a former camogie player and had significant personal experience of such injuries. She thought John would be fine, but since she was not qualified to make that assessment, she brought him to the doctor.The doctor referred John to hospital for an X-ray, which determined that nothing was broken. Even though the social care worker’s assessment was correct, the decision was outside her professional competence, so she was obliged to have it checked.
Case Study 3
Mary presented to a domestic violence refuge with her three young children having been violently assaulted by her partner. The social care staff had significant experience in this area and were very familiar with Mary’s rights and entitlements. Having provided her with the relevant information, staff referred Mary to a solicitor for independent legal advice..
Case Study 4
Michael has Down syndrome. While he cannot live independently, he completes daily independent tasks as part of a community integration intervention. At a pedestrian crossing in the city one day, Michael waited for the green light but while crossing the road was knocked down and injured by a Garda car. Nobody had told Michael that emergency vehicles can go through red lights when their sirens are on.
We can see from the practice examples above that social care workers are constantly managing risk. In some areas, the boundaries of our knowledge, such as when the client requires medical or legal advice, are clearly defined; in other areas they are not.
Knowing when to seek advice
The first thing that comes to mind here is that you should not wait until you are at the limit of your ability before you ask for advice. As a therapist, whenever I feel stuck, or think I ‘need’ advice about the work, I ask the client what they think would help. In my view, the most dangerous and unhelpful position the ‘professional’ human service provider can take is to assume that because of their training or education, they know more about the client than the client knows about themselves. Of course, that statement is dependent to some extent on the client’s age and cognitive ability, but we should never underestimate the client’s ability to know what they need.
I bring some knowledge and experience to my relationship with my clients in social care and psychotherapy. They do the same, and together we try to find solutions to issues that cause a barrier to their quality of life. Throughout that process I will remain open to advice and guidance in all its forms from a variety of sources. I will also use formal professional supervision and team discussion/reflection to its full potential.
Knowing when to seek additional expertise
As a humanistic/integrative therapist and social care worker, I have a bit of a reaction to the word ‘expertise’. I do not see myself as an ‘expert’ on anything but myself. While I always value the input of people with additional knowledge, the suggestion that our clients’ lives should be decided exclusively by those with ‘expertise’ does not always sit comfortably with me. Sometimes our clients need input from family, friends, community members and priests/spiritual advisers. Sometimes they need it from doctors, therapists and solicitors or experts in various other fields. Decisions on how/when to seek additional expertise should be made when there is either an impasse in the work that cannot be resolved internally, or when external input may bring a skillset to the intervention that is particularly useful. When seeking clinical input, it is important to remember, though, that another professional may provide a medical as opposed to a psychosocial response to a problem that may or may not be consistent with the ethos of your agency.
Case Study 5
John was a non-verbal 15-year-old with a moderate learning difficulty and retentive encopresis. His bowel motions occurred once a week, causing him significant pain and discomfort, which manifested in aggressive challenging behaviour. Medical professionals recommended manual bowel evacuations and laxatives, but social care staff noticed that being in a swimming pool stimulated his bowel motions. Staff deferred acting on the medical advice and brought him swimming twice a week, which resolved the issue. They took a great deal of care to get himout of the water in time!
Knowing when to refer to another professional
As previously stated, social care work is about helping the client to take ownership of their own life: it is not about us. If we reach the stage with our client where we are not helpful, for any reason, then we owe it to them (and their family) to refer them to another worker/professional.It would be unreasonable to expect a social care worker to be 100% effective with all their clients all the time. The challenge is to have the awareness and maturity to know where your strengths lie, and not to let your ego get in the way of the work. If you are no longer helpful or need to pass a client on to somebody else, then it is your responsibility to do that. Controlled emotional involvement or over-enmeshment in the client’s world can also be a reason for passing a client on. Carl Rogers said that in humanistic work the necessary elements of the helping relationship are genuineness, empathy and unconditional positive regard (Mearns & Cooper 2005). Empathy is viewing the client’s world through their eyes as if it were your own, but without ever losing the ‘as if’ quality. Some social care workers believe that is it possible to finish work at the end of a shift and leave it all behind. I do not agree. When we care about, and work with, very vulnerable people, I have found that it is almost impossible to completely forget about them outside work. However, we should remember that a job is supposed to support your life; it is not supposed to be your life. When we become enmeshed in our client’s world to the point where it begins to overshadow our private lives, or where workers have strong feelings for a client (love/hate/sexual attraction), we risk our judgement becoming impaired. If that happens and the issue cannot be resolved, we owe it to our client to pass them on to a staff member who can remain impartial.
Tips for Practice Educators
Many social care workers and students still struggle to articulate exactly what we do. This is partly why it has taken us so long to achieve public recognition and professional status. Now that we have a clear and concise definition for our work, it is important that our students learn and understand it, because they cannot know the limits of their practice, if they do not know exactly what their practice is. Students should be encouraged to:
- Understand that professional social care work is far more complex than simply helping vulnerable people.
- Deconstruct the term ‘relationship-based work’ and understand the importance of the dynamics in their relationships with their clients.
- Understand their legal responsibility to their clients.
- Understand that care, protection, psychosocial support and advocacy are the cornerstones of our practice.
- Notice their position of power in the relationship with their clients and always aim to give the client as much control as possible over their own life.
- Be very clear about when their practice could be perceived to cross into another discipline and use supervision and peer support wisely to take advice and guidance in that regard.
- Understand that knowledge is an important prerequisite to professional practice, but a worker with compassion and little knowledge will be far more effective than a worker with knowledge and little compassion!
References
Atkins, K., De Lacey, S., Ripperger, B. and Ripperger, R. (2020) Ethics and the Law for Nurses (4th edn). Cambridge: Cambridge University Press.
Byrne, J. (2009) ‘Personal and Professional Development for Social Care Workers’ in P. Share and K. Lalor (eds) Applied Social Care: An Introduction for Students in Ireland. Dublin: Gill & Macmillan.
CORU (2019) Preparations for Opening the Social Care Workers’ Register. Available at https://www.coru. ie/about-us/registration-boards/social-care-workers-registration-board/updates-on-the-social-care- workers-registration-board/update-on-the-registration-of-social-care-workers/ [accessed 1 March 2021].
Dalrymple, J. and Burke, B. (2006) Anti-oppressive Practice, Social Care and the Law. Berkshire: Open University Press.
Mearns, D. and Cooper, M. (2005) Working at Relational Depth in Counselling and Psychotherapy. London: Sage.
Moss, B. (2008) Communication Skills for Health and Social Care. London: Sage.
O’Connor, I., Hughes, M., Turney, D., Wilson, J. and Setterlund, D. (2003) Social Work and Social Care Practice. London: Sage.
Social Care Workers Registration Board (2019) Social Care Workers Registration Board code of professional conduct and ethics. Dublin: CORU Health and Social Care Regulator. Available at https://coru.ie/files-codes-of-conduct/scwrb-code-of-professional-conduct-and-ethics-for- social-care-workers.pdf.
