Tuesday, September 21, 2010

a new kind of vulnerable

I was having a conversation with a family the other day who were expressing the reality that their ability to financially support the care of their aging parent was fast approaching an end; they were terrified, anxious and burdened by a sense of deep failure. They had already wrestled and fought their way through an earlier and equally difficult predicament - the realization that they could no longer emotionally and physically support their parent at home - the health care needs and the physical toll of caring were simply too much, even with significant formal and informal daily and hourly support. It was a decision in many ways that was long overdue ( at least from the vantage point of the onlooker); the family was exhausted the client was frail. They took solace in the fact that at least at the time of this decision, they were financially in a position to afford private facility care, while they waited for a subsidized bed. The move was immediate, mom settled in well and the family regained a sense of emotional and physical equilibrium. Everyone's need were taken care of; it was looked at as one of those win-win situations.

What no one anticipated though was the devastating impact of a simple change in wait-listing policy. When mum was in the community it was a crisis; her care needs exceeded the capacity and availability of formal health care resources and had overwhelmed the family's capacity to carry the balance of care required. The only viable and realistic option was placement in a care facility; it was clear that her need for placement was considered 'urgent'. Who would have thought that the short term 'fix' the family was able to provide, in terms of paying privately for a facility bed while awaiting a subsidized bed, would have such a punishing outcome as a result of a policy change. Now that she is 'safe and sound' in a facility bed she is no longer considered in need of urgent placement - effectively she has landed on a snake (as in the game snakes and ladders) and has slipped way back in line for a subsidized bed - even though she has been waiting for over a year. The only way she gets to the top of the wait-list, the only condition upon which she would qualify as 'urgently in need of a subsidized bed' is if she and her family were no longer able to pay privately for care; in essence, she and her family have to be flat broke with no other options before the 'system' reconsiders her level of need. Its not that a bed magically appears when this happens - the stars are not so easily aligned - its just that now she fits the criteria for being urgently wait-listed. What happens in the mean time (while the wait is still on for a subsidized bed to become available) is that the she and the family are presented with a few options, of which they are left to decide on the lesser of two evils: one, she can return to the community and be cared for by a collective of informal and formal supports (which was already tried and clearly was insufficient for the level of care required); or two, be admitted to hospital and await placement from there (an undignified, extremely disruptive option for the client, to say nothing of a flagrant misuse of an already overtaxed resource). Simply put the demand for subsidized extended care facility beds significantly outweighs the supply - the 'system' says their hands are tied, there is no money, there are no options - well, no good options anyway.

This is a new and emerging kind of vulnerability - one that explodes from the fragility and precarious nature of an increasingly under-resourced system of care. The trickle down impact of policies written far away from the front lines of care devastates families and clinicians alike. Clinicians are forced into a position of somehow defending a broken system which has reneged on the most basic of promises: to provide continued access to quality health care without financial or other barriers and to protect, promote and restore the physical and mental well-being of residents of Canada. (FYI: these are the stated objectives of Canadian health care policy).

While the system seems okay with offering solutions that are known to be insufficient (returning a client to the community where their needs exceed the capacity of formal and informal resources) and / or are not in the best interest of the patient (ie, will do more harm than good), front-line clinicians do not have the same protected luxury. We are the ones who have to look into the weary and exasperated eyes of patients, their families and caregivers and tell them that the system can no longer guarantee or safeguard their well-being. Where does this leave us? The impact of these policies contravene the objectives of Canadian health care policy, and arguably also contradict the ethical standards of practice of many, if not all, of the professional health care disciplines.

Wednesday, June 23, 2010

It has occured to me that while responding to adult abuse and neglect falls within the domain of health care (at least in the province of BC), it is an uncomfortable fit at best. Situations of abuse and neglect are not acute or chronic medical conditions and therefore cannot be understood as such. Health care clinicians, for the most part, are driven in their assessment, understanding and actions of any given situation by an epistemological stance heavily influenced by a scientific, biomedical understanding of how things work - cause and effect, for example, and that for every problem there is a solution, and that the success of the fix is contingent on how the individual (body, mind, behaviour) responds to whatever solution is offered.

To be fair, abuse and neglect cases are prioritized and responded to swiftly like other crisis situations. This is where perhaps the fit between these issues and the health care system works. If an adult needs immediate safety, shelter and attention for medical conditions that threaten their health then the system is relatively well resourced to provide for these short-term, medically focused, interventions. But it is in the crafting of long-term, effective, appropriate solutions to these complex situations that challenge and expose the shortcomings of the health care system. Responding to situations of abuse and neglect extend well beyond the expertise of medicine; they are lived experiences born from multiple and intersecting social, cultural and historical factors - only some of which are manifested in the body and mind. Responding to these situations requires a different lens, a different language, a different orientation - a paradigm shift that allows and values an exploration of the whole: person, context, environment and the interpersonal relationships in and from which vulnerability, risk, abuse and neglect emerge.

Monday, March 8, 2010

An Orientation to Practice

With every client encounter, I have an opportunity to change the way that they experience the health care system. The way I orientate myself to my work, the way I enter into the space between myself and my client is integral in creating an environment that encourages change, growth, renewal and healing.

Among other things, I along with my esteemed colleague A.S., have been working on articulating an 'orientation to practice' that captures the essense of a culturally safe approach to working in the area of abuse and neglect with vulnerable First Nation adults.

The front line struggle of 'how to be most effective but least intrusive' in responding to reports of abuse and neglect of vulnerable adults is made even more complex when working across culture with vulnerable First Nation adults. Knowing that historically the very presence of health care clinicians (aka. 'outsiders') in the lives of First Nation individuals and communities has been experienced as 'intrusive', I grapple even more with the question of how to do this work well.

Abuse, neglect, vulnerablity... these are not medical conditions that can be cured or fixed with a 'one size fits all' approach. These are complex relational realities influenced greatly by historical circumstances and diverse social factors, the impact of which are not just experienced in the present but woven through and across multiple generations. Responding to and intervening in situations of abuse and neglect is a complex endeavor that extends beyond the limits of medical expertise. It requires clinicians to broaden the scope of understanding to include the historical, social and cultural context of any given situation, the physical, mental, emotional, and spiritual functioning of the vulnerable adult and how the interplay of these elements contribute to a more accurate assessment of vulnerablity, risk and well-being. In my frontline work in this area of practice it has became clear that a different approach is required, a different dialogue and a different level of engagement, particularily when working with vulnerable First Nation adults, their families and in their communities.

The "orientation to practice' that has been articulated in a recent working paper is a 'hybrid' approach, drawing on indigenous knowledge, valuable concepts and models of cross cultural practice and social work theory, insight from research on abuse prevention and social determinants of health, and anecdotal accounts of community abuse prevention and response projects from First Nation communities across Canada. It is a holistic approach that weaves together aboriginal wisdom and worldview with western clinical practice theory creating a broader lens through which risk and vulnerability can be more accurately assessed and health and well-being can be better interpreted, understood and supported. Of particular importance is the recognition that culturally safe practice requires careful, intentional and respectful collaboration between aboriginal and non-aboriginal health care clinicians, service providers and involved community members. The challenge for the clinician is to find ways to respectfully and humbly enter the 'space between' - creating opportunities for full, even conflicting narratives to emerge, taking the time to listen and understand mulitple perspectives, holding sacred these voices and co-creating meaningful and effective responses that mitigate risk and vulnerability and perserve dignity both for the individual and community.