Chapter 3 – Laura Doyle (D1SOP3)
Domain 1 Standard of Proficiency 3
Be able to act in the best interest of service users at all times with due regard to their will and preference
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KEY TERMS Best interests Will and preference Rights-based practice Human rights-based approach
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Social care is … the planning and provision of relationship-based care and supports to people who experience marginalisation and/or disadvantage in society. Relationships are at the core of what social care is and through the promotion of healthy relationships, human rights and advocacy, social care promotes and supports people to reach their full potential. |
Best Interests
In social care we have the privilege of supporting a broad spectrum of vulnerable groups of people, from children and adolescents in residential services to people in direct provision, people with disabilities, people dealing with trauma, among many others. The people with whom we come into contact are deemed to be in need of support, and this support can manifest itself in many different ways. One of our main roles as social care workers is to help by asking what is in the best interests of the person who requires support. In social care we encounter the term ‘best interests’ quite frequently, but what exactly does it mean?
The term ‘best interests’ as a children’s rights principle is derived from the UN Convention on the Rights of the Child, which states that ‘the best interests of the child must be a primary consideration in all actions concerning children’ (UN 1989). ‘Best interests’ is also used as a guiding principle in the Mental Health Act 2001: when making a decision under the Act, the best interests of the person shall be the main consideration. In the Irish context, there is no clear definition of ‘best interests’, which leaves the term open to different interpretations and applications. Walsh (2017) argues that in the legal landscape this has oftentimes led to the courts interpreting this principle in a paternalistic manner. There are many examples of paternalism embedded in Irish history, including the power that the Church held and its devastating impact on people who were placed in educational reform settings and Magdalene laundries ‘for their own good’; and the medicalisation of mental health and disability which led to people being put in institutional settings under the pretext of protecting them and protecting society, by limiting their own personal liberty and autonomy.
But how do we as social care workers determine what are the best interests of a person? Our own values and belief systems can at times influence our decision-making process in relation to care and support. Our own interpretations of best interests could be derived from our own values and beliefs. Our personal values and beliefs can influence our decision-making in many areas of our lives, including our career. Reflective practice can play a vital role in allowing practitioners the space to reflect on these important issues and to critically analyse the role that our values and beliefs might play in our practice. Determining the best interests of a person should not be done in isolation. Best practice would be to include as many people as possible who know the person well and have developed relationships with them. The person receiving support should be involved and included in the dialogue and understanding of what is in their best interests. They should be at the centre of this person- centred approach to their care.
Task 1
Think about your life and what changes would happen (if any) if someone supporting you were to act in your ‘best interests’?
Will and Preference
The proficiency states that as social care workers we need to have due regard to the will and preference of the service user. But what is meant by a person’s ‘will and preference’? Will and preference, like best interests, remains undefined. However, it can be interpreted as how a person wants to live their life and the preferences they have in relation to their personal life choices. These vary from person to person and often change over time. ‘Due regard’ means having the proper care or concern for something. In the context of the proficiency it means that, while working in the best interests of the person, we as practitioners need to properly consider and take into account the will and preference of the person receiving support and to ensure that as far as is practicable these are upheld and respected.
Will and preference, as a term, can be found in the UN Convention on the Rights of Persons with Disabilities (CRPD) (UN 2006). The adoption of the CRPD was a momentous occasion as it formally recognised disability as a human rights issue and reaffirmed that all people with disabilities should enjoy all human rights and freedoms. In Ireland, the introduction of the Assisted Decision-Making (Capacity) Act in 2015 was a monumental step towards recognising the right of all adult citizens to make decisions about their own lives. This Act, once fully enacted, will see the presumption of capacity afforded to all adult citizens regardless of mental health diagnosis, disability or other diagnosis. Under this Act we must presume that all adults have the capacity to make decisions, whether or not we feel they are the right decisions.
How do we as practitioners determine a person’s will and preference? Building relationships is key. Discovery is a process in person-centred planning whereby a person’s goals, wishes and dreams are established using a variety of tools that are individualised to suit the needs of the person. The discovery process is the starting point to building relationships and establishing trust with the person.
It is important that practitioners reflect on these scenarios and seek the appropriate support and guidance.
TASK 2
How would you support a person if their will and preference would impose a risk to that person’s safety or wellbeing?
Questions for a social care worker to reflection when looking at the best interests and will and preference of a person.
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| Best Interests
What are the person’s best interests? Are these best interests agreed upon by the person and/or others? Are the rights of the person respected and upheld at all times? Am I fulfilling my professional obligation to this person? |
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Will and Preference
What are the person’s goals, wishes and dreams? How does the person want to live their life and what is needed to support this? Does the person’s will and preference pose a risk? If so, what can be done to minimise this risk? |
TASK 3
Please reflect on the questions (Best Interests) and (Will and Preference) and apply them to the case study below
Case Study 1
Marian is a 55-year-old woman who lives in a residential home for adults with intellectual disabilities. She smokes 20 cigarettes a day; she has smoked since she was 18 and has negatively responded when asked to stop. Marian continuously gets chest infections and other health complications relating to smoking. Marian’s doctor has advised that she needs to quit smoking for the good of her health. It is in Marian’s best interests to stop smoking; however, her will and preference is to continue. As Marian’s social care worker, how would you support Marian in the context of the proficiency ‘be able to act in the best interests of service users at all times with due regard to their will and preference’?
Human Rights-Based Approach
In recent times there has been an emphasis on a human rights-based approach to care in Ireland. The Health Information and Quality Authority (HIQA), in conjunction with Safeguarding Ireland, has developed a guidance document on a rights-based approach, Guidance to Support a Human Rights- Based Approach in Health and Social Care Services, which was partly funded by the Irish Human Rights and Equality Commission (HIQA 2019). As practitioners, we operate within the legal parameters of service and support provision. It is imperative that we know, and are aware of the importance of knowing, the rights of the people we provided support to and to ensure that support and interventions are delivered in a way that is respectful of these rights.
According to Curtice and Exworthy (2010), in a human rights-based approach to care the clinical processes, organisational practices and culture of a service support and protect the human rights of people who use the service. It is ‘the process by which human rights can be protected by adherence to underlying core values of fairness, respect, equality, dignity and autonomy, or FREDA’ (Curtice & Exworthy 2010: 150). It is important that we as social care workers understand these principles and are able to apply them to our practice.
While operating in a practice in which we must act in the person’s best interests, with due regard to will and preference, we must, as practitioners, be cognisant of the rights of the person and ensure that we are not working in a manner that means these principles are not respected or promoted. Equally, we must be cognisant of our obligations to people who receive support to promote their safety, health and wellbeing at all times and take all reasonable actions to support these.
Figure 2: Awareness of our own values and beliefs play a vital part in supporting an HRBA and supporting the will and preference of a person.
TASK 4
How would you promote and support a rights-based approach in practice?
It is important as practitioners that we are aware of our value system and are cognisant of imposing that same value system on others. For example, if a social care worker values health and healthy eating they must be careful not to impose their values on others who might not share similar values or beliefs. One of the ways we do this is through our reflective practice. Values are not stagnant – they can change over time – which is why it is important to continuously reflect on our own values and how they might influence our practice. Equally we must be aware of our own limitations in defining what is in the best interests of a person, the person themselves and the people who know the person well. Determining what is in a person’s ‘best interests’ should not be done in isolation; it needs to be a collaborative approach with the person involved, as much as is practicable, and at the centre of all discussions.
Discovering the ‘best interests’ and the ‘will and preference’ of a person begins with establishing a relationship with the person in order to learn more about them. This process can take time and should be done at a pace that the person is comfortable with. This relationship needs to be genuine and built on trust in order for the person to respond positively to the process and to engage with you as a practitioner. As social care workers we will come across difficult cases, ones in which the will and preference of a person could be in direct conflict with what is deemed to be in their best interests. In these cases it is imperative that the dignity and rights of the person are upheld at all times and that the practitioner is aware of their own legal obligations.
TASK 5
Think about and reflect on your own values. What would you do if you were supporting someone whose value system was different from your own?
Tips for Practice Educators
Students will need to reflect on their own interpretations of what ‘best interests’ means to them. This can be done through the student reflecting on their own values and beliefs. One tool which can be useful to use is the coat of arms, a tool whereby the student reflects on what is important to them and puts this into their own coat of arms. The student should then be encouraged to think about situations in which they are supporting someone whose values and beliefs are in conflict with their own: how would they respond? The importance of diversity should be highlighted to show how our values and beliefs are often in conflict with those of others and that as practitioners we need to be able to respond appropriately in these situations and be aware that we do not impose our own values and beliefs on others in the context of best interests.
A key requirement for understanding and applying this proficiency is the student’s understanding of the role that relationships play when determining the best interests and will and preference of the person they are supporting. Students need to have a clear understanding of their own interpretations of best interests and how this can influence their decision-making. Reflective practice and a collaborative approach are key to implementing this proficiency in practice. Students need to have a thorough understanding of this and to be able to use these approaches in practice.
Relationships are also key to helping a practitioner discover the will and preference of a person. The discovery process can be used to support relationship-building and to help determine a person’s will and preference. The discovery process for person-centred planning can be applied to a wide variety of settings and the various tools used to support the process can be applied in relationship building with the person. The coat of arms, the circle of support and my perfect day are just a sample of tools that can be adapted and individualised to suit each person. Students should have an understanding of person-centred planning and the various tools used in this approach to inform other areas of their work and to help support relationship-building.
Person-centred Planning Tools
Coat of Arms – A tool to support a person to think of what means the most to them in their life, what they truly value, and to design their own coat of arms around this. The person is supported to draw and reflect on their values and why they are important to them. Available from https://www.nga.gov/content/dam/ngaweb/Education/learning-resources/ lessons-activities/greco-roman-myths/coat-of-arms.pdf.
Circle of Support – A tool which maps out all the people in the person’s life. This tool can be also used as a great learning tool to support boundaries and different relationships. Available from https://www.mentalhealth.org.uk/sites/default/files/a-guide-to-circles-of-support.pdf
My Perfect Day – A tool used to facilitate a conversation about what constitutes a perfect day for the person. This helps the social care worker establish what is important for the person and also to identify some of the person’s goals, wishes and dreams. http://helensandersonassociates.co.uk/person-centred-practice/person-centred-thinking-tools/
References
Curtice M, and Exworthy, T. (2010) ‘FREDA: A human rights-based approach to healthcare’, The Psychiatrist 34(4): 150-6.
Government of Ireland (2001) Mental Health Act 2001. Dublin: Stationery Office.
Government of Ireland (2015) Assisted Decision-Making (Capacity) Act 2015. Dublin: Stationery Office.
HIQA (Health Information and Quality Authority) (2019) Guidance on a Human Rights-Based Approach to Care and Support in Health and Social Care Settings. Dublin: Stationery Office.
UN (United Nations) (1989) Convention on the Rights of the Child. Available at: <https://www.ohchr.org/ en/professionalinterest/pages/crc.aspx> [Accessed 15 January 2020].
UN (2006) Convention on the Rights of Persons with Disabilities. New York: United Nations.
Walsh, K. (2017) ‘Best Interests – Some Perspectives’ (online) <https://www.ucc.ie/academic/law/docs/ mentalhealth/conferences/2017/10.10-K.Walsh-08Apr2017.pdf> [accessed 14 January 2020].
