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Roles and relationships
If you are a service user of mental health services, there is an expectation that you comply with the care and treatment offered to you. And if you are a nurse manager, you are expected to comply with the terms of your job description and adhere to professional guidelines.
One OU student wrote: 'Conflicts between home and work life are the most relevant. The responsibilities of both can sometimes cause friction when there is not enough time to manage everything.'
Although your list will reflect your own situation, there are several challenges that affect all roles and relationships:
Role conflict occurs when someone is expected to carry out two or more contradictory roles in the same situation, while role incompatibility happens when there is a mismatch between people's expectations of roles. Role incompatibility appears to be similar to role conflict but, while the latter suggests that resolution is possible, the former suggests that there is no solution to the challenge presented by incompatible roles. Role blurring and reversal can occur when workers talk about their personal troubles to service users.
The boundaries between people who are in relationships with each other are often defined by the roles these people play. The difference in power between service users and workers imposes one such boundary.
Ethics - Power and relationship boundaries
'Power over', which has been described as social power, is the ability to use incentives to bring about desired outcomes.
Incentives are often employed according to the 'carrot and stick' formula, where praise can be the positive incentive, or 'carrot', and the threat of punishment can be the negative incentive, or 'stick'. In both cases, the person with 'power over' uses the incentives to obtain their desired outcome.
Dowding points out that achieving outcomes by using power over others can be done blatantly or subtly. He describes incentive structures that involve a broad range of benefits and costs that arise from one or other kind of behaviour.
An example of this from the 1980s is of the 'token economy' schemes in psychiatric hospitals, where cigarettes were awarded for good behaviour (Sheldon 2004).
In mental health services, the exercise of social power is wide ranging. For example, with the professed intention of helping out, professionals can 'take over' certain situations and by doing so, in the eyes of many service users, introduce or perpetuate paternalistic power relationships and prevent self-determination and autonomy.
The power of professionals is often bolstered by mental health legislation. There may be implicit or explicit recognition that behaving in one way but not another results in implementing legislation leading to, for example, compulsory detention. Service users may be told that, if they refuse to go into hospital as voluntary patients, they will be admitted formally under mental health legislation.
Ethics - Challenging relationships: the example of observation
Charis says: 'It was a very traumatic experience. It was incredibly intrusive and invasive to me and I am a very private person.
Siobhan says: 'Continuous observation is about different kind of boundaries. It's about physical boundaries, emotional boundaries, person-to-person, person-to-patient, professional-to-patient boundaries.
The dichotomy identified by Charis and Siobhan, and some of the arguments for and against continuous observation, are in Box 1.
Ethics - Regulation of boundaries
You might think that you regulate your relationships well enough without guidance, but special issues arise out of relationships between workers and service users, such as the imbalance of power and possibility of exploitation, and the need for openness and transparency, which make some regulation necessary.
Professional documents or codes, statements of values or legislation may therefore be helpful (Box 2). These guidelines and statements give no specific guidance on what constitutes acceptable or unacceptable behaviour but they are based on certain values that presume what is, and therefore what is not, acceptable or appropriate.
Delegates at a web based conference organised by the Mental Health Foundation last year on the role of values in mental health proposed a 'national framework of values for mental health' that:
• recognises the role that shared values play in shaping the views and attitudes of individuals, in and across all stakeholder groups
According to members of the National Institute for Mental Health in England (NIMHE), underlying the conference was a belief that 'values in mental health reflect and interact with values in society as a whole'.
They also pointed out that 'values are particularly important in the field of mental health with its complex interplay of issues around trust, power, responsibility, risk, safety, "duty of care" and service user empowerment' (NIMHE Values Project Group 2002).
However, they also note that there is little reflection on the planning, delivery and commissioning of services where the values embodied by these standards come into conflict. Fulford et al 2002 describe two themes:
• A key theme of the national service framework (NSF) is the user centred approach but 'users', like any other group of people, present a diverse range of personal and collective values. These values relate to their beliefs, aspirations, cultural backgrounds and lifestyles, as well as their experience and understanding of mental health problems and expectations of services. So an 'acceptable' intervention and a 'good' outcome for one may be 'unacceptable' and 'bad' for another.
• Another key NSF theme is the emphasis on multidisciplinary teams. Again, teams are very diverse, and different team members have different skills and different values. A social worker may be concerned with risk, for example, a nurse or psychiatrist with compliance and a manager with client throughput. Mental health organisations themselves have different corporate values that may not be shared by other agencies or accord with those of their staff or users and family members
Activity 1: Allow 15mins
Box 1: Arguments for and against continuous observation
• Values life
• Whose life is it anyway?
Reflection Exercise #4
Ethics CEU QUESTION 11
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