Identifying and critically analysing the ethical and practice dilemmas resulting from an actual (anonymous) practice situation.
Identifying and critically analysing the ethical and practice dilemmas
resulting from an actual (anonymous) practice situation.
I have chosen to critically analyse a practice situation based on a woman called Mary. Her name has been changed for my assignment so that she can remain anonymous. When reading her case I found it had a very powerful impact on me and made me more aware of how the Mental Health system works and what the results are if a service user is admitted to hospital and purely 'ignored' by staff.
I will be analysing the ethical and practice dilemmas by focussing on her journey through the different hospitals she was referred to and what the results were from Mary's situation.
I will look at what could have been done to prevent such a nightmare for Mary and are there any improvements that can be made to ensure this does not happen again?
I will be looking at the ethical dilemmas that occurred throughout Mary's ordeal and who was to blame. I will be focussing on the Mental Health Act and comparing it to Mary's situation to see if the Act was followed and what the Act involves.
From analysing Mary's case it has made me strongly consider working in Mental Health as a qualified Social Worker. My wish would be to never allow this to happen and for Mary to have been listened to by medical staff. I know as a Social Worker I will be challenged by practitioners because of my opinions and decision-makings and through my learning I will be able to face them with what I believe is right. I know however in reality that such a nightmare can occur again because of the little time Social Workers have to spend with their service users, this however I hope can change.
'On average one in four of us will experience a mental health problem in the course of a year. These problems can cause real and lasting damage, both to the individual and to the community. Fortunately the majority of people who experience mental health problems can get over them or learn to live with them especially if they get help early on.' (Mental Health Foundation, 2000)
Her psychiatrist had described Mary of having 'borderline personality disorder'. This however had not been explained to Mary and she was unclear as to what it meant. She first stopped feeling her usual self after an operation (her first). She began to develop anorexia nervosa; No-one noticed this, neither her family nor her work colleagues. She then soon became obsessed with exercising and would exercise for hours without stopping:
'Eating disorders involve serious disturbances of the 'normal' eating pattern, and an obsessive concentration on body size and diet. These disorders can be seen on a continuum from minimal intervention in the community through to life threatening conditions that require specialist residential services' (Golightly, M, 2004, p.72)
Mary was first admitted to her first hospital on December 1988. She was left to her own devices and not one of the staff explained to her what was wrong. There was no assessment for Mary so her needs were not met to the full, therefor leaving her confused and upset:
'The main purpose of any assessment is to obtain accurate, that is, reliable and valid, information about facts and attitudes and feelings. The purpose of the assessment should be clear; otherwise no judgement can be made about the relevance of the information collected. The informant should ...
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Mary was first admitted to her first hospital on December 1988. She was left to her own devices and not one of the staff explained to her what was wrong. There was no assessment for Mary so her needs were not met to the full, therefor leaving her confused and upset:
'The main purpose of any assessment is to obtain accurate, that is, reliable and valid, information about facts and attitudes and feelings. The purpose of the assessment should be clear; otherwise no judgement can be made about the relevance of the information collected. The informant should be clear about the purpose of the assessment so that he/she can give relevant information.' (Huxley, P, 1985, p.29)
This first main interview could have been the beginning of a better relationship between the worker and Mary and it is important to establish a rapport from the start. This could have relieved the anxieties Mary had and would have explained what it is the nurse does, what the assessment is for and what would happen next.
Mary was admitted to hospital, arrived voluntarily but she was empowered by the medical staff from the moment she set foot through the door, Benner (1984) has stated that the power resides in the 'power of caring' and 'excellence in caring,' and that relinquishment of those nurturing activities will impede all moves towards self-determination. Mary waited for hours to see a doctor and when she finally did it was only brief. Her first contact with a nurse came shortly after another patient became distressed and started throwing hospital equipment around. The nurses predicted that Mary wouldn't be there the following night. She in fact stayed for 5 months.
The nurses didn't interact with the patients, they only did if they were asked, and so things naturally 'spiralled.' What Mary wanted most of all what to spoken/listened to, she wanted a service that would be responsive to her needs and if possible, provide a range of alternatives to hospital admission:
'Listening is an active process and all hospital staff need to be skilled at their process and be prepared to spend time listening to them.' (Golightly, M, 2004, p.100)
There are many ethical issues in social work today. One being, Issues around individual rights and welfare-'a user's right to make her own decisions and choices; the social worker's responsibility to promote the welfare of the user' (Banks, S, 1995, p.11) There is no mention of a social worker being present in Mary's case, however if there had been they would have carried out an assessment on Mary and they would have given her a voice by expressing her needs and feelings ultimately, ethical issues ultimately involve consideration of what is 'right' and what is 'wrong'. Ethics are about everyday actions, as well as the higher consideration of their value. Mary felt helpless and afraid and didn't know how to ask for help, she was unsure of what was wrong with her or why.
Mary was discharged from the hospital being in a worse state that when she entered, she was then admitted to an Eating Disorder unit. The Eating Disorder Service is a specialist service for individuals who are suffering from anorexia nervosa, or bulimia nervosa. The service aims to help patients: gain weight and/or to establish regular eating patterns so that they can gain control over their eating disorder, help patients come to an understanding of eating disorders and of their likely causes and consequences.
'Treatment is based on cognitive behavioural therapy, motivational enhancement therapy and family work and is delivered by members of the multidisciplinary team.' (NHS Clinical Services Directory, 2005)
Mary was scared of food and believed the eating regime reinforced this fear. In this unit Mary first became sectioned. The most common sections that are used to admit someone to hospital are section 2 up to 28 days in detention in hospital for assessment and treatment. If a family member objects to this they are able to appeal against this decision. Section 3 up to 6 months detention in hospital for treatment and section 4, which is up to 72 hours in cases of emergency. These sections come under the Mental Health Act 1983. People can only be detained if the strict criteria laid down in the Act are met. The person must be suffering from a mental disorder as defined by the Act.
'The Mental Health Act 1983 covers the assessment, treatment and rights of people with a mental health condition.
Many people receive specialist mental health care and treatment in the community. However, some people can experience severe mental health problems that require admission to hospital for assessment and treatment.' (DirectGov 2003)
Most people who receive treatment in hospitals or psychiatric units for mental health conditions are there on a voluntary basis and have the same rights as people receiving treatment for physical illnesses.
However, a small number of patients may need to be compulsorily detained under a section of the Mental Health Act.
The Act explains who is involved in the decision about compulsory admission or detention, and the individuals, or their nearest relative's right of appeal. Mary does not mention in her case as to whether any one appealed the decision to section her, however if there was a family member to appeal they have the final decision on Mary's welfare. The appointment of the nearest relative can only be changed by a County Court. The nearest relative's power of discharge can be overruled by the doctor who is responsible for the patient's treatment.
There have been many improvements made to offer better treatment and to better safe guards for patients and the public. One being the New Draft Mental Health Bill. This revised Bill is the biggest reform of mental health legislation since the 1950's. It will provide improved safeguards for patients and better procedures for treatment to the small minority of people with mental health problems who need to be treated against their will to prevent them from harming themselves. Mary on many occasions had tried to commit suicide by self-harming after spending two years in hospital suffering from a deep depression:
'There are many reasons as to why people would do this including self-punishment to gain feelings of control, clearing their mind, expressing their psychological turmoil physically and the adrenaline rush that the body naturally releases during these actions' (Coppock, V, Hopton, J, 2000, p.145)
The National Mental Health Association aims to provide Cognitive (talk therapy) and behavioural (changing behaviour) therapies which 'aim at relieving the despair of suicidal patients by showing them other solutions to their problems and new ways to think about themselves and their world. Behavioural methods, such as training in assertiveness, problem-solving, social skills, and muscle relaxation, may reduce depression and anxiety.
Cognitive and behavioural homework assignments are planned in collaboration with the patient and explained as experiments that will be educational even if they fail. The therapist emphasises that the patient is doing most of the work, because it is especially important for a suicidal person not to see the therapist as necessary for their survival.
The Mental Health Act has one of the most powerful innovations, the regulations of treatment for mental disorder for non-consenting patients detained under part four of the 1984 MHA. The medical treatment for informal patients in psychiatric hospitals in many ways mirrors that of patients in general hospitals and they have the right to refuse treatment.
'Medical treatment means a range of interventions including drug treatments, nursing care, therapeutic interventions, and could include behaviour modification and task centred work.' (Golightly, M, 2004, p.55)
The NHS has developed Care in the Community, which provides a flexible range of services to take account of the requirements of individuals and their carers. By talking with the person and, when appropriate, the people who look after him or her, a variety of care and support services may be arranged. This will often assist people to carry on living in the community.
They will give priority to prevention and assessment services so that hospital admissions are reduced to a minimum:
'The aim of the Mental Health Team is to improve the quality of a person's life by helping them understand the problems they face, together with making objective plans for alleviating the situation.' (Direct.Gov 2004)
Mary suffered 'neglect' at the face of the professionals. The whole case was lacking in communication and she was left to defend for herself. She lacked the power of speaking up in fear of getting things wrong. She was constantly told she was being assessed; yet she never knew what for. The change that needs to occur is not a large shift in clinical intent but simply a realisation that professional assertiveness, linked with the human virtues inherent within a consequentialist sense of purpose, must be part of professional nursing. The nurses of Mary had a duty to keep her informed of what was going on, because they didn't they therefor defied all aspects of ethics within professional practice.
I hope that as a social worker I can promote some kind of change in ensuring that this doesn't happen again, when in theory I know this can not be the case because of little time social worker's have. No matter what services are on offer it is clearly the government's intention that nurses, medical practitioners and social workers should work together to provide better services for service users. Carpenter et al. (2003) suggests that in the move towards integration 'social workers are finding it more difficult to adapt and are among the most stressed among the professional groups.' Besides being 'stressed' there are a lot of positive aspects to social work, that is why I am hoping to qualify so I can make a difference to someone's life.
0404650 Mental Health Word Count: 2,119
