Category Archives: law

Who put us in charge?

A short video introduction to the principles of the mental capacity act 2005.

Who put us in charge?

If you’d like to arrange training for your staff please complete and send the contact form below.

Carers in mind: Concerning confidentiality

Confidentiality form 3Confidentiality can be a real headache for carers. Whether their loved one is being cared for by the NHS or by some other health or social care organisation they often have great difficulty in getting the information they need to care for their relative or friend as the vital part of the care team that they actually are. But does this really need to be the case?

It’s true, of course that people have the right to privacy, including those people who need care services – a fact that few carers would deny or seek to change. But patients and service-users don’t necessarily want to keep EVERYTHING private. Very often the problem arises, not because people have the right to confidentiality but because of the way that workers approach the issue when discussing confidentiality with them in the first place.

It’s important to be nuanced in matters of confidentiality. too often the question is asked…

“Do you want your family to know about your care?”

Really we ought to be far more specific. We need to differentiate more between the types of information we can disclose and that we should not. After all, there can’t be too many young men who would want their mothers to know all about their sex lives or other, equally personal details. Professional care workers need to be much more specific about the types of information to be disclosed and also about which family members or friends it will be disclosed to.

Most carers don’t want the intimate details of personal issues anyway. They do want to understand about medication regimes, care planning, symptoms and side effects, relapse profiles and plans and they need to know who to contact when things go wrong. This requires far more nuanced discussions than typically happen in over-stretched care services. So here’s my solution…

Click here to download a form that you can use to help workers determine just what information can be shared and with whom. It takes all the difficulty out of the equation for care workers by providing them with clear, unambiguous guidance about what they can and cannot disclose.

It is important that the form is completed collaboratively with a representative of the professional care team. The organisation working with the patient or service-user will have legal issues to consider and the worker may need to speak to their management about the form. Don’t ‘ambush’ them with the form. Let them know about it in advance. Ideally give them a copy to discuss with their management first. That way there should be no problems when you do sit down to complete it.

Complete this form at a time when the patient has the mental capacity to make the decision. Staff will not be able to abide by confidentiality decisions made when the patient lacks the capacity to decide.

Please feel free to get in touch, especially let me know of your experiences in using the form. It’d be great to hear from you.

 

A duty of care myth

Hanged if you do… hanged if you don’t!

Many people are confused about their duty of care. They think they’re somehow responsible for the actions of other people. This leads them to try and prevent people from doing things that they have a perfect right to do because it might be risky. In truth our duty of care is actually much simpler than most people imagine:

  • Do all that you reasonably can;
  • Don’t break the law;
  • You are not responsible for the actions of other people;
  • You are responsible for your own actions in the situation you’re in;
  • Care workers are judged upon process, not outcome.

Complete the contact form below to arrange training for your staff.

Mental health training – a short sample

This abridged, edited audio (& video slideshow) is taken from the introductory session of a 2012 mental health training day in Glasgow. Although not all of the session is included it gives a flavour of the day, the topics to be considered, the training aims and the insights to be expected throughout the day.

You can find a longer version (26 minutes) by clicking below…

Training courses

Complete the contact form below to arrange training for your staff.

Safeguarding: An established process, not a civil liberties dilemma

I first published this article 7 years ago. It’s unfortunate that so many people still fail to understand the need for robust Safeguarding processes, especially when the same people often express mock outrage at child abuse cases that the Safeguarding system attempts (& often manages) to prevent.

Child and ​Adult Protection have become increasing concerns over recent years. Several high profile incidents involving abuse of vulnerable people have prompted UK society to look again at the systems we have in place to safeguard those who need it most.

Social media currently features ill-informed and often frankly unconvincing outrage on behalf of Rachel Booth, a school dinner lady who attended a rally organised by Tommy Robinson (EDL founder & notorious Islamaphobe).

Mrs Booth has been suspended from her job as a result of her attendance at the far right rally. She has broken no law and is not being charged with any crime yet her job is in jeopardy (an inquiry is ongoing). Many people consider this to be abusive and an affront to freedom of speech. One particularly ill-informed right-winger even describes it as a ‘thought crime’, reminiscent of Orwell’s dystopian novel ‘1984’.

The inappropriateness & ironic hyperbole of this far right Tweeter’s statement is obvious when you realise what inspired it. Pastor Martin Neimoller was writing about German Nazism, a regime not unlike Robinson’s EDL. The Nazis executed vast swathes of people from minority or politically inexpedient groups without a hearing, often simply because of who they were. The British Safeguarding system aims to ensure the safety of vulnerable people and minorities through proper investigation focusing upon what people do.

As a trainer I am convinced that people make sense of things best when they know the ‘how’ and the ‘why’ as well as just the ‘what’. So read on to understand why this suspension isn’t only appropriate but, in Safeguarding terms, absolutely necessary.

We’ll begin with the Protection of Vulnerable Adults (POVA) system. This was introduced by the Care Standards Act 2000 with guidance from the government’s ‘No Secrets’ document. This outlined the definitions of abuse and of vulnerable adult. It also created the POVA list – a register of the names of people who were deemed to be unfit to work with vulnerable people because they represented too high a risk.

The POVA list was one of three basic lists:

1.The POVA list: related to vulnerable adults
2.The POCA list: related to children
3.List 99: Related to education

These three lists were operated by different organisations but all relied upon the enhanced CRB check. The CRB check (Criminal Records Bureau) check provided information on criminal convictions. The enhanced CRB check provided more than just this basic information. It also noted suspicions and unproven allegations that might be relevant.

When delivering training on adult protection and safeguarding I almost always come across objections when I make this point. This is understandable because it seems to contradict the long-standing legal principle of the presumption of innocence: the idea that we are innocent until proven guilty.

My response to this is always to put forward the following hypothetical scenario from the world of child protection:

Imagine a teacher – a good teacher – we’ll call him ‘Bill’. Bill has been in the job for many years and gets great academic results for most of the children he teaches. Bill specialises in the 7 – 11 year old age bracket.

Some of the children Bill teaches tend to do very badly though. They tend to be little girls with blonde hair and they often become withdrawn and emotionally needy shortly after joining Bill’s classes. I don’t think I need to be too specific here – the results of paedophilia are well known and the above scenario illustrates the point well enough.

Now imagine that this teacher has been working in a particular school here in Cumbria for a few years when he notices that some of the parents have taken to ignoring him. Bill also notices that when they’re waiting for their children at the school gates some of the parents tend to bunch together and seem rather conspiratorial whenever they see him. Bill’s no fool. He knows what’s about to happen. It won’t be very long before he’s formally reported to the local police.

So Bill applies for other jobs in other schools out of the area. His overall academic record is good and the head will give him a good reference (not least because she’s heard the rumours too and wants rid of the problem). Bill leaves Cumbria and takes up a post in a school in the neighbouring county of Lancashire. There’s no conviction and so no information follows him. He’s in a different education authority with a clean slate.

A couple of years later, having continued his abuses with a fresh group of Lancastrian children, Bill moves again, perhaps to Lincolnshire this time. And then a year or two later he moves once more – this time to your home town. Now Bill’s teaching your children.

That’s OK isn’t it?

It doesn’t take a genius to understand that if we can only use convictions to identify abusers we will fail more often than we succeed. But this gave us a dilemma as a nation. Whatever we do we cannot have a perfect system – mistakes will be made. The choice we have had to make as a society, the way through the dilemma, is to consider what the price of our mistakes will be.

If we rely upon convictions only then the price will be countless abused children. Exactly the scenario that ‘libertarians’ like the quoted Twitter-user & far right Islamaphobes like Tommy Robinson claim to oppose. Imagine how many youngsters a teacher will come across in the space of a career. How many vulnerable elderly residents might an abusive ’carer’ come into contact with too?

If we use wider sources of information the price of our mistakes will be some people having to get a different job. Neither outcome is ideal but then it’s not an ideal world. Which price do you consider to be the lesser of two evils? I think – and the government thinks – that the lesser price is the fact that some people will need to get a different job.

So child protection systems solved the problem, at least in part, by considering wider information and adult protection has followed suit – hence the enhanced CRB check (now the DBS). Even then it doesn’t necessarily mean that the individual whose information shows up on the check is barred from working in the care sector but they may have some things to discuss with prospective employers at interview.

Only in the more extreme cases are people actually prevented from working with vulnerable adults and that was what the old POVA list was about. People whose names ended up on the POVA list were legally barred from working in social care.

In 2005 Kings College London produced a report analysing the first 100 referrals to the POVA list. Their findings were significant and in parts very worrying. The document can be viewed online here.

Firstly it was clear that the vast majority of referrals came from the independent sector with only around 5% of referrals generated by the NHS. This is unlikely to be because the NHS does not have any abuse issues – in fact it may demonstrate a culture of neglect and ‘turning a blind eye’ that needs to be addressed as a matter of urgency. When abuse in the NHS does come to light it is often extreme and systemic as was demonstrated in the North Cornwall scandal of 2006.

The report also noted that in many cases abusive practice had been tolerated and left to continue for long periods. This was especially true in smaller establishments. The vast majority of abuse involved front line workers.

Perhaps most worryingly several workers had actually been convicted of relevant offences and yet continued to work in health or social care. The main arguments put forward in mitigation by those accused of abuse were:

Overwork;
Lack of training (particularly relating to challenging behaviour and hostility);
Accidental harm/lack of intent to cause harm;
Mental health problems experienced by the alleged abuser (often linked to working conditions).

“In our reading of the referrals there appeared sometimes to be a merging of poor skills and abuse”

The Kings College report acknowledged the reality of many of these mitigating circumstances and asked for greater scrutiny of employers and their practices when determining the truth of such allegations:

“As a means of reducing harm to vulnerable adults, it is clearly important to ensure that people of general ill-will or those who lack capacity are prevented from working in social care. However, it is also important to balance the focus on individual abusers and episodes of abuse with a wider examination on the quality
of social care employment practice, availability of training, working conditions, impact of under-staffing and ongoing nature of stress.”

“Consequently, it is possible that previous CSCI reports on the provider unit or company may be a valuable addition to the information to be considered in making decisions about referrals. In situations in which a worker claims not to have had training, examination of such records may help provide better evidence. Furthermore, some referrals included evidence about staffing levels at the time of and immediately preceding the incident or periods of misconduct would be useful. Such evidence may help in deciding individual cases, but also identify situations which might give rise to ongoing concern about the safety of service users in those establishments.”

Although several workers were dismissed and some were reported to the police not all of them were prosecuted. This is because it can be difficult to establish guilt in a court (beyond reasonable doubt) even when there is enough evidence (balance of probabilities) to dismiss them.

Differing ‘burden of proof’ has been a long-standing problem, especially in child protection. Child protection (CP) is an area of practice that has provided many answers to problematic issues and so it was used as a basic blueprint to guide adult safeguarding procedures.

Other problems identified by this and subsequent studies involved the lack of partnership working between sectors and what appears to be an element of ‘preciousness’ in some local authorities with regard to the sharing both of information and of resources.

In response to these sorts of concerns and also serious incidents such as the Soham murders (Ian Huntley) and the case of Miss X (Scottish Borders Enquiry) new legislation was drawn up and has been implemented throughout UK.

References and further reading

Department of Health (2000) No Secrets: Guidance on developing and
implementing multi-agency policies and procedures to protect vulnerable adults
from abuse, London, Department of Health.

Department of Health (2004a) Protection of vulnerable adults scheme in England
and Wales for care homes and domiciliary care agencies: a practical guide,
London, Department of Health.

Department of Health (2004b) ‘P1.1 Rounded Referrals, Assessments and
Packages of Care, for adults’ Report of findings from the 2003-04 RAP
Collection, London, Department of Health.

Fyson, R., Kitson, D. and Corbett, A. (2004) ‘Learning disability, abuse and
inquiry’, in: Stanley, N. and Manthorpe, J. (eds) The Age of Inquiry: Learning and blaming in health and social care, London, Routledge.

Health & Social Care Information Centre (2004) Community Care Statistics 2004:
Home care services for adults, England, London, Department of Health

House of Commons Health Select Committee (2004) Report on Elder Abuse,
London, The Stationery Office.

Mathew, D., Brown, H., Kingston, P., McCreadie, C. and Askham, J. (2002) ‘The
response to No Secrets’, The Journal of Adult Protection, 4(1) pp. 4-14.

Social Care Workforce Research Unit 2007) Partnership and Regulation in Adult Protection http://www.prap.group.shef.ac.uk/PRAP_report_final_Dec07.pdf

Summer, K. (2004) ‘Social services’ progress in implementing No Secrets – an
analysis of codes of practice’, Journal of Adult Protection, 6(1) pp. 4-12.

The Nursing and Midwifery Council (2004a) Reporting lack of competence: A
guide for employers and managers, London, NMC.

The Nursing and Midwifery Council (2004b) Reporting unfitness to practise: A
guide for employers and managers, London, NMC.

This bulk of this (now slightly updated) article first appeared on Stuart’s personal blog early in 2010. It has been reposted here in response to current events.

To arrange training for your staff please complete the contact form below…

Doing the rights thing

​So many nationalists talk about how great UK is. They cite our history, particularly 20th century history and the post-war society they grew up in. And I agree – for all its faults, post-WW2 UK hasn’t been a bad place to grow up in.

Our emphasis on justice, compassion, tolerance and human rights has created a pretty cool place to live. We have education, health care, protection for workers, unemployed people and the sick and disabled. We have a reasonable justice system without barbarity and access to legal remedy for all. It’s true that  recent ideologically driven austerity measures have definitely impacted negatively on most of these advantages. None the less most UK adults today grew up with a working set of rights and safeguards before recent governments began trying to remove them.

What seems odd to me is the way that, whilst extolling our nation’s virtues, these nationalists often want to remove the emphasis on rights, tolerance, representative democracy and justice that made modern UK society so good in the first place.

Why is that? I think it’s probably because they don’t quite get the reality of Human Rights and what they’re in place to achieve. For years now the media and certain politicians have distorted the public’s perception of human rights with a parade of half-truths and downright deceptions.

My solution is to develop a training pack, primarily for care workers but actually relevant across society to help show people what’s at stake as the UK prepares to leave the EU. There is a lot of talk about scrapping our human rights. I think we need to be very, very clear about just what that means – and about what we want to come next. Knowledge is power!

Please get in touch if you have any suggestions for topics to include, FAQs to prepare for or any other questions or comments about this new project.

Many thanks.

Stuart

Human rights in the UK?

Everyone should read and understand this. We need the Human Rights Act and the European Convention on Human Rights. Without them this vicious tory government realky will be able to treat us all like expendable cattle.

https://kittysjones.wordpress.com/2014/08/16/uk-becomes-the-first-country-to-face-a-un-inquiry-into-disability-rights-violations/

We are more than just working stock for the moneyed establishment.
Those who cannot work are more than just burdens – they are people.

Don’t be fooled. Human Rights laws are there for a reason. We cannot afford to lose our HR protections.

Course design 13: Take the time to tell the tale

The following is the text of an article I first wrote for ‘Local government Lawyer’ magazine. You can find it online here:

http://localgovernmentlawyer.co.uk/index.php?option=com_content&view=article&id=7057%3Alessons-in-law&catid=52%3Aadult-social-services-articles&q=&Itemid=20

Lessons in law meme“Lessons in law      

Thursday, 23 June 2011

The right approach to training in health and social care law can make a world of difference, writes Stuart Sorensen.

The abuse of vulnerable adults at Winterbourne View Hospital was extreme, dramatic and horrific. That’s presumably why Panorama chose to investigate it and why it has received so much attention from both press and public. Many bloggers have jumped on the scandal to make a point, some moral and some procedural. I have done as much myself. Several of us have taken the opportunity to write about specific legal issues from the Mental Capacity Act and the Deprivation of Liberty Safeguards to the Mental Health Act and the European Convention on Human Rights. It’s always helpful to have a topical ‘angle’ to focus upon when discussing law.

Unfortunately though this sort of blogging often becomes an exercise in futility. Those people who are interested in matters of law will most likely already be familiar with the principles discussed, or at least know how to find out about them. Those who are not, who simply want to know more about the human drama unfolding as a result of the programme will simply ignore the legal stuff in favour of more lurid pieces. For many the very thought of trying to understand legal concepts conjures up images of dusty textbooks and overly complicated jargon that might as well be written in a foreign language. There’s a perception of inaccessibility that discourages many people from even trying to understand. That’s where I come in.

I’m not a lawyer – I’m a nurse. A mental health nurse to be exact. I’m also a trainer. Oh yes – and I’m a bit of a geek with a passion for law. Well, everybody needs a hobby.

So it’s not too surprising that I regularly find myself training nurses, care workers, social workers, doctors and even police officers on health and social care law related issues. I must have trained tens of thousands of people over the years on topics such as the Mental Capacity Act, the Deprivation of Liberty Safeguards, the Safeguarding Vulnerable Groups Act and its Scottish equivalents the Protection of Vulnerable Groups (Scotland) Act and the Adult Support and Protection (Scotland) Act. Does that make me an international trainer? I doubt it but a nurse can dream.

During these sessions one theme is almost constant. People come into the training expecting to be bored. They also expect to be confused by a topic that they will not be able to relate to and that has little or nothing to do with their everyday experience. Not the best starting place for a jobbing trainer like me.

The problem is that many legal trainers have never taken the time to understand how health and social care workers learn. We’re different from lawyers – at least I think we are. There are many ways to think about learning styles and personality types and generalisations can be misleading but here goes anyway. In my experience health and social care staff from support workers to social workers tend to be more or less ‘top down’ learners. If the training was a jigsaw they’d like to see the picture on the box before they even start to look at the individual pieces.

Introducing care professionals to the minutiae of doctrine has its place but not until they understand the broad picture – the background and purpose of the particular act and how it relates to their work on a day to day basis. These people are not lawyers, they don’t generally think like lawyers and very often they don’t even start with the basic point that the law can help and protect them.

There is a culture of resentment in health and social care, especially regarding mental capacity, rights and safeguarding legislation. It’s not because people would prefer to be abusive – it’s because they don’t understand the law well enough to realise how positive it can be. So we begin with the basics, the purpose, the background and the scope. And we do it through story. This allows us to pull out the basic principles that we will rely upon and return to throughout the rest of the training. It sets up a basic foundation, the ‘picture on the box’ and gives participants the confidence to engage without fear of looking ‘stupid’.

Care workers tend to be ‘hands on’ people. We don’t usually ‘do’ abstract nearly so well as we ‘do’ tangible. That’s not to suggest that we’re not capable, far from it. But tangible is the ‘default’. As a rule we work with people and we get involved in the narrative of their lives. That’s what we do. It’s also how we learn.

So for Safeguarding we begin with Soham and with Miss X. For the Mental Capacity Act we tell the Bournewood story and from this month DoLS training will start with Hillingdon and the ‘Neary case’. By using narrative right from the start we draw people into a world that they’re already familiar with. By asking questions throughout the stories we begin to relate legal constructs to everyday scenarios:

What should the social worker have done?

How should the care worker react?

Is this good practice? If not, why not?

Before they realise it the participants have gone from work to law without a hiccup. This is the value of narrative. From stories and case studies to participants’ own experiences and even newspaper headlines, stories work. Stories are memorable, stories are accessible and stories help people to ‘grock’, to assimilate the true meaning of the law.

That may seem obvious. Indeed it is obvious but it’s also depressingly uncommon. I genuinely have lost count of the number of people who’ve told me how much easier to understand they found social care law after narrative based training. I won’t bore readers with their reports of previous, ‘chapter and verse’ style training but I’m sure you can imagine.

So if you’re a lawyer, a trainer or a social worker with the responsibility for delivering health and social care law training to care workers remember the rule of ‘T’:

Take The Time To Tell The Tale

 

Privileged glimpses 25: Who put us in charge?

This series of blog posts first appeared a few years ago on a now defunct blog called ‘Care Training’. It was inspired by the training maxim of ‘making the unconscious conscious’. It is intended to take what really ought to be the most basic principles of health and social care and put them down on paper. The series isn’t only an exercise in stating the obvious though whatever the title might suggest. It’s actually intended as a philosophical foundation manual for workers and informal carers to help them get their care ‘on track’ and then to keep it that way.

The first of the Mental Capacity Act’s underlying principles is:

An assumption of capacity

This means that we need to begin by assuming that everyone we meet is capable of making this particular decision at this particular time unless we have reason to suspect otherwise. In other words that person is ‘Most people’ in relation to the ‘three types of legal status’ table below:

Three types of legal status

Most people

Make their own decision

Bournewood gap

Follow Mental Capacity Act 2005

Mental Health Act

Follow Mental Health Act 1983/2007

People whose capacity to make the decision is not in doubt People who are not detained under the MHA but who lack the capacity to decide People who (because of a mental disorder) are deemed to present a risk to self, risk to other or are at risk through self-neglect.

This might seem very obvious and reasonable (in fact it is) but it doesn’t sit too well with common practice in a number of care environments. Let’s look at an example.

When I was still a young man I worked as a care assistant in a Learning disabilities residential home. Looking back I can see a number of problems with the way the home was run but at the time, having come into a system that was already established, I thought that this was how learning disabilities establishments were supposed to operate. I didn’t know any better.

One of the fundamental mistakes I used to make related to the residents’ ability to make choices. This mistake covered all sorts of decisions from what to watch on the TV to whether or not they wanted to come on group outings to the local swimming pool.

The house was set in its own grounds in a beautiful part of Lincolnshire and the lawn and garden were nothing short of stunning. The home employed a full time groundsman to keep everything in good order and he did an excellent job. Consequently, many of the residents used to enjoy spending time sitting under the trees in the grounds or walking around the landscaped garden.

However this wasn’t always possible. You see, along with all the other staff there, I would take it upon myself to stop residents at the door and expect them to explain to me why they were safe to go outside. If I wasn’t completely satisfied then I would prevent them from doing so – this wasn’t difficult because the doors were always locked and only the staff had keys. Only if I was happy for them to leave would I let them go outside.

The problem was that this was the wrong way around. I emphasised the word let in bold for good reason. You see it wasn’t up to me to let people do anything.

We use the word ‘let’ a great deal in health and social care but that implies an authority we do not usually have. I can only let a person do something if I have the legal power to prevent them – and usually I don’t.

It wasn’t up to me to let people go outside into their own garden. They went because they had a right to and unless I had good reason to interfere with that they didn’t need my permission at all.

A more recent illustration of this comes from the N. Cornwall Learning Disabilities Partnership NHS Trust inquiry that took place in 2006. There were 40 referrals to the POVA list (now the vetting and barring list) and many of them were to do with staff preventing people from using areas that they had a right to without good reason.

Whenever we are tempted to take control of other peoples’ choices it’s useful to begin by asking ourselves:

“Who put me in charge?”

Unless you can demonstrate that the individual lacks the capacity to make this particular decision at this particular time then nobody put you in charge. The person has a legal right to make their choices whether we like it or not.

Even if the person lacks capacity (in which case you may very well be ‘in charge’) you will still need to act in their best interests and that doesn’t automatically mean doing what is best for the staff or for the relatives.

People have the right to occupy their own space, to make decisions about when they get up or go to bed, to choose who they spend time with and whether or not to involve themselves in activities. They also have the right to disagree with us and to ignore the preferences of family members just as you have. Your relatives have no right to tell you what to do (assuming you’re an adult) and the same is true for your service-user with capacity.

Who put us in charge?

Privileged glimpses 20: Do we need help?

This series of blog posts first appeared a few years ago on a now defunct blog called ‘Care Training’. It was inspired by the training maxim of ‘making the unconscious conscious’. It is intended to take what really ought to be the most basic principles of health and social care and put them down on paper. The series isn’t only an exercise in stating the obvious though whatever the title might suggest. It’s actually intended as a philosophical foundation manual for workers and informal carers to help them get their care ‘on track’ and then to keep it that way.

Do we need help?

Let’s look at two other ‘categories’ of challenging behaviour:

  • Behaviours that we can cope with;
  • Behaviours that are beyond our ability or authority.

Behaviours that we can cope with

These are behaviours that fall within our own skill set and area of expertise. For example a care home resident refusing to bathe from time to time. It is well within the authority of the staff to decide how best to handle it. However, if the refusal is accompanied by signs of depression or dementia for example then the larger multi-disciplinary team may well need to be involved.

For example, I remember working with a young drug-user who simply stopped going to bed. Instead he would sleep in the communal lounge on the settee. Speaking with him (not ‘to’ him, by the way) seemed to make him more determined to sleep in the lounge, even though the settee was too short and uncomfortable. So we decided simply to stop mentioning it.

We provided an alternative area for other service-users and ignored the fact that he was sleeping in the communal lounge altogether. We didn’t even mention it when he started to complain of back pain. We simply suggested that he might want to see his GP about pain relief. He didn’t make the appointment but he did stop sleeping on the settee.

The decision to stand back and wait for him to learn ‘the lesson of experience’ was ours to make and the situation was remarkably easy to resolve. Often ‘the path of least resistance’ really is the way to deal with things that are within our remit to solve.

Behaviours that are beyond our ability or authority to cope with

When I was a community psychiatric nurse I had a client who regularly called me reporting that she’d taken an overdose and asking for an ambulance. Actually I’ve had several clients who did that over the years.

The more I responded the more frequently she called. She didn’t always tell the truth (sometimes she had overdosed and sometimes she hadn’t) but I had no way to know in advance.

I wanted to stop responding to these situations because by reacting to the phone calls I was only making things worse. However, I needed the support of the multi-disciplinary team first. So I called a meeting involving all the relevant workers, the service-user herself and (with permission) her brother was also present

We decided upon a new care plan. Essentially we all agreed (including the service-user) that if she was able to call me she was also able to call an ambulance if that was what she needed. We therefore agreed that I would expect her to do precisely that in the future. If she called me reporting an overdose I would advise her to call an ambulance and remind her of our scheduled appointment time (which may be some time in the future).

The behaviour stopped working for her and she stopped. She called in these circumstances only twice more before changing tack and talking about her real problems instead. I’m not going to pretend that the problem she presented next was easy to resolve by any means but at least we got to focus upon the thing that mattered instead of a haze of challenging behaviours that served only to distract us both from the real work we had before us.

The point here is that although I ended up doing precisely what I thought was right I needed the backing of the multi-disciplinary team first. Their ‘blessing’ was important.

Sometimes we need others to get involved when we discuss what we need to do about a situation. There’s no problem with that – it’s just appropriate.

Incidentally this doesn’t mean that the decision not to respond to my overdosing service-user was a ‘team decision’. It was always my decision how to respond when I picked up the ‘phone (and I could have changed my mind had circumstances demanded it). Team meetings don’t take away our responsibility for our own decisions – if you’re ‘on the spot’ you decide what to do – but they do make those decisions easier to defend if we need to. My decision was safer because I had discussed the situation with the team and they had agreed with my strategy.

Had I not discussed the situation with the multi-disciplinary team and my client really had overdosed I’d have had a hard time explaining my actions to the ensuing inquiry. As it was – had she come to grief (she didn’t but she might have) I’d have been able to defend my decision precisely because of the involvement of the team.