New series to support the Policing Degree

We have recently launched a new series of Study Skills books which are ideal for anyone undertaking a policing degree. Here one of the authors, Martin Wright, gives an idea of his motivation for writing the series.

It is a real pleasure to be invited to write a short note regards the new study skills books for policing degree students. Together with my excellent co-authors, Jane Bottomley and Steve Pryjmachuk we have prepared four texts that we believe provide a great introduction to help you succeed in your studies. The books provide essential guidance and instruction on how to study for a policing degree, how to think and write critically and how to communicate effectively. The books have been specifically designed to complement the three degree entry routes into policing and are both topical and challenging.

With the police and policing never seemingly out of the news and the recent announcement of increased funding for the establishment of a large number of new constable posts universities are well-placed to support both the education and professionalisation agenda set by the College of Policing. For lecturers and course leaders the books provide a really accessible set of formative tasks that can assist their teaching. With the increased focus and investment by universities in policing there could not be a more opportune moment for staff to utilise within their programmes. In turn, any student applying to undertake a policing degree at university the books will provide them with a real head-start on their course and clear guidance as to how to succeed in their studies.

We do hope the books are found to be of very real benefit to university staff and students alike and in time assist in the professional development of policing.

Find out more about the series by clicking here.

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Getting carers healthy and connected in their communities

The theme for Carers Week 2019 is: ‘Getting carers healthy and connected in their communities’.

When I became a carer for my daughter in 2002, I was forced to juggle both looking after my other children and a stressful job as a social worker. I was exhausted, emotional and was desperate for both information and support from people who understood. Although caring is a privilege and may be rewarding, it can still be incredibly hard work. It took me many years to admit that and to ask for help.

I believe that talking about these issues and bringing ‘care’ to the forefront as a society will make us stronger as individuals and collectively. Carers Week 2019 (June 10th to 16th) offers an opportunity to raise the profile of carers as well as celebrating and recognising the work that goes on behind the scenes.

In Working with Family Carers, a book inspired by my own experiences, I discuss some of the issues faced by carers in the UK. From identifying carers and providing information and advice and, given the likelihood of practitioners themselves providing (and receiving) care, it also offers a discussion regarding maintaining resilience and the extent to which personal experiences guide and inform practitioners response to work with carers.

Statistics show there are over 7 million carers in the UK, a number acknowledged to be seriously underestimated .We know that at least one in five of us will become carers in our life time. Caring needs to be seen as a part of life, the majority of us will be givers and receivers of care at some point and sharing information and supporting each other will help us all in understanding the importance of care. Organisations such as The Carers Trust and Carers UK are great sources of information for carers, students, and practitioners.

I personally appreciate the work of both organisations who supported me during some very stressful times, and because of this, I have chosen to donate all the royalties from my book Working with Family Carers to be shared equally between Carers Trust and Carers UK as a way to acknowledge this and give a little back.

Valerie Gant April 2019

A Pain in the Neck: A Critical Review on the Efficacy and Risks of Cervical Spinal Collars in the Prehospital Environment

Sara photo

This essay was written by Sara Marr-Phillips and is the winning nursing entry in the 2019 Critical Writing Prize. Sara is studying at Greenwich University and was nominated by her lecturer Scott Goudie.

Abstract
This review critically discussed the evidence for and against the use of cervical collars on trauma patients with a suspected spinal injury in a pre-hospital setting. The efficacy of cervical spinal collars to immobilise patients has been widely debated over the last 30 years. A growing body of evidence suggests that cervical collars may be ineffective at immobilising the cervical spine and increase the risk of raised intercranial pressure, inducement of pain, pressure ulcers, dysphagia, restricted ventilation, increased risk of aspiration, a compromised airway and mortality. To this date no randomised control trials for the use of cervical spinal collars has been carried out. Considering concerns have been ongoing over the last 30 years around the use of cervical collars, the growing body of evidence of associated risks, and little or no evidence validating their use, provides a great deal of justification for starting randomised control trials to assess the
efficacy of using cervical spinal collars in the prehospital setting.

Key words: Cervical collar; Prehospital care; Trauma; Spinal cord injuries; Spinal
immobilisation.

Introduction 
This review will critically discuss the evidence for and against the use of cervical collars on trauma patients with a suspected spinal injury in a pre-hospital setting. The efficacy of cervical spinal collars to immobilise patients has been widely debated in recent years (Sundstrøm, et al., 2014). In the UK each year, approximately 1000 people sustain a new spinal cord injury (SCI) and, as of 2016, 40,000 people are living with the long-term disabilities as a result (National Clinical Guideline Centre UK, 2016). Approximately 15% of those with a spinal column fracture or dislocation will also have an SCI (National Clinical Guideline Centre UK, 2016). This makes them relatively rare with cervical spinal injuries accounting for approximately 2% of hospital admissions (Davis, et al., 1993).  For the year 2015-2016, ambulance trusts in the UK collectively spent £441,103 on cervical collars with individual trust expenditure ranging from £804 to £71,990 (Veljanoski, et al., 2017). Due to growing pressure on the national health service (NHS) and the need to be more cost efficient than ever before; money spent on a piece of equipment that is currently controversial due to a growing body of research questioning the need to use such immobilisation techniques, whilst potentially causing further harm, could be an inefficient use of funds.

History of the Cervical Collar
The cervical collar was first implemented in 1967; it come in to use during the Vietnam war to evacuate soldiers with spinal injuries (Rogers, 2017; Arishita, et al., 1989). Patents from the time include that by George Cottrell (Cottrell, 1966) and Glenn Hare (Hare, 1974) which are the precursors to cervical collars used today. They are described as providing traction of the cervical spine and a degree of immobilisation (Cottrell, 1966). The assumptions that have led to spinal immobilisations are: that the injured patients could have an unstable cervical spine injury, movement may cause additional damage, application of a semi-rigid cervical collar will help prevent these movements, and immobilisation as a procedure is ‘relatively harmless’ so can be applied ‘as a precaution’ (Benger & Blackham, 2009). This perceived lack of risk and application as a failsafe will be further discussed and how it ties to current recommendations.

Current Recommendations 
Ambulance trusts in the UK follow the Joint Royal Colleges Ambulance Liaison
Committee (JRCALC) UK ambulance services clinical practice guidelines, National Institute for Health and Care Excellence (NICE) guidelines and local trust policies in their decision to immobilise patients (JRCALC, 2016; JRCALC, 2017; National Clinical Guideline Centre UK, 2016). The JRCALC state that patients, with the possibility of a spinal injury indicated using the JRCALC (2017) algorithm, should have the whole spine immobilised either by manual immobilisation or with collar, head blocks and spinal support (JRCALC, 2017). Additionally, NICE guidelines recommend protection of the spinal cord from point of injury to avoid secondary SCI using devices such as cervical collars to immobilise the spine and prevent movement (National Clinical Guideline Centre UK, 2016). It is, however, important to note that in the most recent edition of the JRCALC and NICE guidelines more emphasis has been put on defining cases that would be unsuitable for immobilisation with a collar allowing clinicians to use their discretion (JRCALC, 2017; National Clinical Guideline Centre UK, 2016).  In addition to UK based guidelines, the American College of Surgeons (ACS) and the PreHospital Trauma Life Support (PHTLS) guidelines also advocated the use of semi rigid collars as a prioritised procedure in trauma patients (ACS Committee on Trauma, 2012; PHTLS Committee of the National Association of Emergency Medical Technicians in Cooperation with the Committee on Trauma of the ACS, 2010). These guidelines have been adopted by over 50 countries worldwide (Sundstrøm, et al., 2014). With so many countries invested in the use of
cervical collars it is more important now to consider how effective they are and if there are any risks not previously considered.

Cervical Collars Efficacy
Multiple reviews have looked at the evidence in practice for the effectiveness of cervical collars at reducing movement in the cervical spine since the Cochrane review of evidence in 2001 (Benger & Blackham, 2009; Sundstrøm, et al., 2014; Kwan, et al., 2001). Due to a decrease in incidences and death from spinal injuries around the same time cervical collars and immobilisation were implemented in the 1970’s-80’s, assumptions were made that these changes in mortality were due to their implementation (Kornhall, et al., 2017; ACS Committee on Trauma, 2012). They have been used for more than 30 years in countries all over the world, however, there has been limited evidence to support their use (Sundstrøm, et al., 2014; Benger & Blackham, 2009; Kwan, et al., 2001). This may be due to the quick implementation during the Vietnam war for a way to save lives where time was not available to adequately test new equipment. Moreover, there has been a growing amount of evidence for the adverse effects of cervical collars (Benger & Blackham, 2009).  Due to a growing interest in the mid to late 90’s, a Cochrane report was carried out in 2001 to quantify the effect of different immobilisation methods in trauma patients had on spinal stability, neurological disability, adverse effects, and mortality (Kwan, et al., 2001). They identified 4453 eligible reports, however, not a single trial met the inclusion criteria of being a randomised control trial comparing immobilisation strategies in trauma patients with suspected spinal cord injury (Kwan, et al., 2001). This is a remarkable number of reports to not meet the inclusion criteria and speaks volumes around the style of research that has been carried out so far. This identifies a strong need for development of randomised control trials in this area, however, ethical consideration remains at the fore front when considering these types of trials on patients. To gain ethical approval for studies of this kind, where there is the potential of harm to patients, all other avenues of research showing the lack of efficacy in cervical collars and their risks must be exhausted.

One of the most important studies was carried out by Hauswald et al. (1998). They carried out a five-year retrospective chart review in two hospitals to look at the effect of spinal immobilisation on neurological outcome in blunt trauma patients. One was the University of Malaya in Malaysia and the other at the University of New Mexico, Unites States of America. All the patients taken to the U.S. hospital had their spines immobilised at the site of injury, whereas, none that were taken to the Malaysian hospital were immobilised (Hauswald, et al., 1998). These two hospitals had similar radiological, resuscitative, and surgical abilities. This study found a less than 2% chance that the immobilisation had any beneficial effect on the neurological outcome of these patients (Hauswald, et al., 1998). This would suggest that the perceived risk associated with moving a patient with a potential spinal injury without immobilisation may be unfounded. A number of studies have set out to investigate the range of movement possible whilst wearing a cervical collar in non-clinical participants to assess whether they provide the level of immobilisation that their past reputation has been built on (Sundstrøm, et al., 2014). Ben-Galium et al. (2010) carried out a study using nine fresh human cadavers with simulated unstable cervical injuries. They found that, although the cervical collars did not cause the initial injury, they caused significant separation between the vertebras after application. Cervical collars have been suggested to prevent secondary injury, however, this study provides evidence that the cervical collars themselves may be causing some degree of secondary injuries. Although this is a
small study on cadavers, this model has been seen to be indistinguishable from asymptomatic live participants (Ben-Galium, et al., 2010).

In elderly patients, due to the mechanism of injury and possible pre-existing degenerative spinal diseases, cervical spinal fractures are more prevalent (Peck, et al., 2018). Rao et al. (2016) carried out a study on patients that were over 65 and had suffer major trauma, using CT scans to measure the patients chin-brow horizontal angles whilst lying flat (Rao, et al., 2016). The expectation that if ‘neutral alignment’ was the same for all patients then the chin-brow horizontal angles would be similar, however, this study found that the angles varied widely (Rao, et al., 2016). This suggest that trying to put the elderly patients into the classic ‘neutral alignment’ would in fact be out of alignment for what is normal to them. This may exacerbate possible adverse effects from a cervical collar whilst being immobilised, increase the chances of further fractures in those with osteoporosis and the development of pressure ulcers (Peck, et al., 2018). Although generalisation of these results is problematic due to the small sample size of this study, both Rao, et al. (2016) and Peck, at al. (2018) provide more evidence that collars are not providing the level of protection they have long been praised for providing.  A novel approach measuring the efficacy of methods for immobilising the cervical spine prehospitally was carried out by Rhamatalla et al. (2019). Using a dynamic simulation model, they were able to measure the most effective way of immobilising the cervical spine during transport. They tested 4 measures: a cot alone, cot and cervical collar, long board, collar and head blocks, and vacuum mattress and collar. They found that the long board and vacuum mattress measures were the most effective at immobilising the cervical spine. This study provides a previously unexplored measure of the cervical spine in transport. Future studies should use this style of approach to measure movement across the whole patient journey. It is important to note, however, that this study did not repeat the measures with the collar removed, therefore, it is not possible to say whether the cervical collar was effective or not.

Possible Adverse Effects of Cervical Collars
More recent research has highlighted a number of other risks that have been attributed to rigid collar immobilisation. These include: increased intercranial pressure (ICP), inducement of pain, pressure ulcer (PU), dysphagia, restricted ventilation, increased risk of aspiration, a compromised airway and increased mortality (JRCALC, 2017; Moscote-Salazar, et al., 2018; Tsutsumi, et al., 2018). Although some discomfort is expected with manual handling of patients when being transferred from a prehospital to hospital environment; this growing list of risk highlights some previously unconsidered points to be studied further.

Firstly, it has been suggested that cervical collars raise ICP which can lead to intracranial injury (Mobbs, et al., 2002). Mobbs et al. (2002) carried out a study to investigate changes in ICP after the application of a hard collar in trauma patients with a head injury. ICP was measured without a collar, and at three and five minute intervals after application. Significantly higher ICP was found after the application of the collar. This study provides some insight into the experiences of real trauma patients, however, with such a small sample size, further investigations into the impact of hard collars is required to make meaningful conclusions. Suggestions for this raise in ICP include interference with venous drainage, and pain (Mobbs, et al., 2002; Moscote-Salazar, et al., 2017). Further investigation would be required to elaborate on these results with a larger patient sample size and with a more general trauma rather than specifically studying head injuries. A review of studies researching ICP found that there was not enough data currently to support this hypothesis (Moscote-Salazar, et al., 2017).

Secondly, it has been suggested that cervical collars cause PU’s. Ham et al. (2014) carried out a literature review spanning from 1970 to 2011 searching for studies that have measured PUs in patients having undergone spinal immobilisation. They found that PU’s relating to cervical collars ranged from 6.8% to 38% across different studies (Ham, et al., 2014). PU risk factors include: high pressure and pain from immobilisation, length of time immobilised, high injury severity scores, intensive care unit admission, mechanical ventilation and ICP monitoring (Ham, et al., 2014). Of the 13 studies that met the inclusion requirements; only four were clinical studies. They provided suggestions for prevention or reduction of PU’s which included: early replacement of the collar, collar refit and position change (Ham, et al., 2014). This review supports the need for greater clinical research in understanding the risks of PU’s. 

In regard to a compromised airway, Heath (1994) found that when comparing laryngoscopy of patients wearing a cervical collar and those manually immobilised, 64% of the patients wearing a collar had poor views, and mouth opening was significantly reduced. Although time has passed since this study was carried out, it is still an important study in regard to endotracheal intubation in the trauma patient. This highlights the difficulties in the increased risk of aspiration, compromised airway, and difficulties intubating patients that are wearing a cervical collar. Priority of effective oxygenation of the patient should not be diminished by the need to immobilise the cervical spine. Future studies should also keep this in consideration. 

Moreover, in respect to their effect on mortality, Tsutsumi et al. (2018) carried out a retrospective cohort study from the Japan trauma data bank (JTDB) for patients treated 2004-2015 to look at the effect of spinal immobilisation on traumatic cardiac arrest outcomes. 4313 patients were included in this study with 3307 classed as immobilised (back board and cervical collar) and 1006 as non-immobilised. This study found that the return of spontaneous circulation (ROSC) occurred in 25% of patients that were immobilised compared with 41.9% of non immobilised patients before arriving at the hospital. Furthermore, only 1.8% of the immobilised patients survived to discharge compared with the 3.7% that were not immobilised. This study showed that immobilisation was significantly associated with a lower rate of ROSC by the time of admission and survival to discharge (Tsutsumi, et al., 2018). This could be due to a reduced on scene time as immobilising patients takes a longer period of time to complete, however, there were no significant differences between the groups in the total time taken from arriving on scene to the time to hospital (Tsutsumi, et al., 2018). It can therefore be hypothesised that the collar and board are associated with compromising airway management and raising ICP (Tsutsumi, et al., 2018). 


Although there are some clinical differences between countries to be considered, this is a large study which provides evidence for increased survival rate among the non-immobilised group. More studies could use clinicians’ decisions not to immobilise patients as a way of looking at patient outcomes without actively making the ethical decision to not immobilise by study design. This comes with its own limitations as we would need to account for reasons why clinicians made the discussion to not immobilise in order to make valid conclusions from the results and ascertaining causation. It is important to note that even with this increased survival rate, the number of patients surviving to discharge from a traumatic cardiac arrest is still extremely low.
 
Manual In-line Stabilisation and Lateral Trauma Position
Prasarn et al. (2012) found significant movement during the application and removal of cervical collars. It is possible that the use of cervical collars to immobilise patients is helpful in reducing the risk of secondary injury, however, the process of applying the collar may result in the significant increase in separation noted by Ben-Galium, et al. (2010).  MILS (Manual in-line stabilisation) could be used to negate this risk (Prasarn, et al., 2012). MILS involve holding the head in-line with the attendants’ hands, providing immobilisation (Sundstrøm, et al., 2014). If collars are to continue being used, they should be applied and removed using MILS only by trained professionals, moreover, there would be a need for practice in this skill in order to maintain the high level of care required during the application and removal process (Prasarn, et al., 2012).

Some researchers have considered the use of MILS and lateral trauma position (LTP) to reduce or remove the need for cervical collars altogether. By holding the patients’ head in-line manually the need for collars and blocks are removed whilst still providing a level of immobilisation. The LTP is a variation on the recovery position whereby the patient is log rolled on to their side with their top leg bent at the knee at a 90-degree angle (Kornhall, et al., 2017). This can be achieved with just 2 people (Kornhall, et al., 2017). As with cervical collars, there is limited evidence for their use but there is a growing body of research and support for using these alternative methods of immobilisation in prehospital settings (Kwan, et al., 2001; Kornhall, et al.,
2017).

Discussion 
The use of cervical collars has been based off historical rhetoric rather than scientific evidence (Kornhall, et al., 2017). To date, the existing evidence for their use is weak and, moreover, there is evidence to suggest they do the patient more harm (Kwan, et al., 2001). Current reviews suggest either not using cervical collars in the first place or, if using them, removing them at the earliest possible moment once in hospital (Sundstrøm, et al., 2014), although it is recommended that MILS is used to support the application and removal (Prasarn, et al., 2012). Benger and Blackham (2009) go further to recommend that alert and stable trauma patients do not require immobilisation and the patient should choose a comfortable position to lie in. Their routine use comes at a price that could be reduced if they were used only in the most necessary of cases rather than just as a precaution (Veljanoski, et al., 2017) or the removal of this procedure completely (Hauswald, et al., 1998). There is some evidence for the use of MILS and LTP instead, however, these also need further research as to their efficacy (Kwan, et al., 2001). Guidelines should encourage pre-hospital staff to move away from immobilising a patient ‘as a precaution’ routinely and support techniques that have good quality evidence supporting their efficacy. 

The Cochrane review by Kwan et al. (2001) highlights a lack of randomised control trials in the use of cervical spinal collars. To this date no study has been carried out to provide this insight. Considering concerns have been ongoing over the last 30 years around the use of cervical collars, the growing body of evidence of associated risks and little or no evidence validating their use provides a great deal of justification for starting randomised control trials to assess the efficacy of using cervical spinal collars in the prehospital setting.

References

American College Surgeons Committee on Trauma, (2012). Advanced Trauma Life Support (ATLS) Student Course Manual. 9th ed. Chicago(IL): Americal College of Surgeons.

Arishita, G. I., Vayer, J. J. & Bellamy , R. F., (1989). Cervical Spine Immobilization of Penetrating Neck Wounds in a Hostile Environment. The Journal of Trauma, 29(3), pp. 332-337.

Ben-Galium, P. et al., (2010). Extrication Collars Can Result in Abnormal Separation Between Vertebrae in the Presence of a Dissociative Injury. Journal of Trauma, 69(2), pp. 447-450.

Benger, J. & Blackham, J., (2009). Why Do We Put Cervical Collars on Conscious Trauma Patients?. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 17(44).

Cottrell, G. W., (1966). Cervical Collar. Portland, Oreg., Patent No. 3285244.

Davis, J. W., Phreaner, D. L., Hoyt, D. B. & Mackersie, R. C., (1993). The Etiology of Missed Cervical Spine Injuries. The Journal of Trauma: Injury, Infection, and Critical Care, 34(3), pp. 342-346.

Ham, W., Schookhoven, L., Schuurmans, M. J. & Leenen, L. P. H., (2014). Pressure Ulcers from Spinal Immobilization in Trauma patients: A Systematic Review. Journal of Trauma Acute Car Surgery, Volume 76, pp. 1131-1141.

Hare, G. F., (1974). Cervical Collar. Encinitas, Calif., Patent No. 3850164. Hauswald, M., Ong, G., Tandberg, D. & Omar, Z., (1998). Out-of-hospital Spinal Immobilization: Its Effect of Neurologic Injury. Academic Emergency Medicine, 5(3), pp. 214-219.

Heath, K. J., (1994). The Effect on Laryngoscopy of Different Cervical Spine Immobilization Techniques. Anaesthesia, 49(10), pp. 843-845.

Joint Royal Colleges Ambulance Liaison Committee, (2016). UK Ambulance Services Clinical Practice Guidelines. Bridgewater: Class Professional.

Joint Royal Colleges Ambulance Liaison Committee, (2017). Clinical Practice Supplementary Guidelines. Bridgewater: Class Professional Publishing.

Kornhall, D. K. et al., (2017). The Norweigian Guidelines for the Pre-hospital Management of Adults with Potential Spinal Injury. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 25(2).

Kwan, I., Bunn, F. & Roberts, I. G., (2001). Spinal Immobilisation for Trauma Patients. The Cochrane Library, Issue 2.

Mobbs, R. J., Stoodley, M. A. & Fuller, J., (2002). Effect of Cervical Hard Collar on Intracranial Pressure After Head Injury. ANZ Journal of Surgery, Volume 72, pp. 389-391.

Moscote-Salazar, L. R., Godoy, D. A., Agrawal, A. & Rubiano, A. M., (2017). Effect of Cervical Collars on Intracranial Pressure in Patients with Head Neurotrauma. Journal of Emergency Practice and Trauma, 4(1), pp. 1-2.

National Clinical Guideline Centre UK, (2016). Spinal Injury: Assessment and Initial Management .

Peck, G. E., Shipway, D. J. H., Tsang, K. & Fertheman, M., (2018). Cervical Spine Immobilisation in the Elderly: A Literature Review. British Journal of Neurosurgery.

Prasarn, M. L. et al., (2012). Motion Generated in the Unstable Cervical Spine During the Application and Removal of Cervical Immobilisation Collars. Journal of Trauma Acute Care Surgery, 72(6), pp. 1609-1603.

Prehospital Trauma Life Support Committee of the National Association of Emergency Medical Technicians in Cooperation with the Committee on Trauma of the American College of Surgeons, (2010).

Prehospital Trauma Life Support (PHTLS). 7th ed. Burlington(MA): Jones & Bartlett Learning. Rao, P. J. et al., (2016). Cervical Spine Immobilisation in the elderly population. Journal of Spine Surgery, 2(1), pp. 41-46.

Rhamatalla, S. et al., (2019). Comparing the Efficacy of Methods for Immobilizing the Cervical Spine. Spine, 44(1), pp. 32-40. Rogers, L., (2017). No Place for the Rigid Cervical Collar in Pre-hospital Care. International Paramedic Practice, 7(1).

Sundstrøm, T. et al., (2014). Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review. Journal of Neurotrauma, 31(6), pp. 531-540.

Tsutsumi, Y. et al., (2018). Association Between Spinal Immobilization and Survival at Discharge for On-scene Blunt Traumatic Cardiac Arrest: A Nationwide Retrospective Cohort Study. Injury, 49(1), pp. 124-129.

Veljanoski, D., Grier, G. & Wilson, M. H., (2017). Counting the Cost of Cervical Collars. Prehospital and Disaster Medicine , 32(6), p. 701.

Reducing the gender pay gap: Could more women in STEM be the answer?

Amanda photo

This essay was written by Amanda Summers and is the winning education entry in the 2019 Critical Writing Prize. Amanda, a student at the University of Derby was nominated by her lecturer, Jennifer Marshall.

Introduction

The gender pay gap is a measure of the difference between the median wages earned by men and by women (OECD, 2018c). Despite policies initiated by various governments to reduce gender inequality the gender pay gap remains a persistent problem worldwide. Indeed, recent data (Figure 1) shows that median wages earned by men outstrip those earned by women in every country in the OECD (OECD, 2018c).

figure 1

Figure 1: Gender wage gap (Total, % of male median wage, 2016 or latest available) for countries in the OECD. Source: OECD (2018c).

Notably, the UK has a gender pay gap above the OECD average and it is one of the highest in Western Europe. Prime Minister Theresa May has described this as one of “the burning injustices which mar our society” (May, 2018) and has committed the UK government to reducing gender pay inequality (Conservative Party, 2017). In this report I will examine the role of education in reducing the gender pay gap. Particularly, I will look at the gender pay gap of graduates in the UK, and how this is influenced by the degree subject choices of women. I will also examine evidence from Malaysia, a country which has successfully encouraged more women to study science, technology, engineering and maths (STEM) (Tienxhi, 2017), and will discuss the effect of this on gender pay inequality.

The gender pay gap and the role of education

In almost all OECD countries, including the UK, the number of women enrolling in higher education exceeds that of men (OECD, 2018b). However, as previously highlighted, this does not translate into long term economic advantage for women. A recent analysis of the UK Longitudinal Education Outcomes (LEO) data by the Department for Education revealed that just one year after graduation male earnings exceeded female earnings by 9%, with the gap widening to 30% ten years after graduation (Department for Education, 2018). It should be noted that the data is not longitudinal in the strictest sense, as it does not follow a single cohort of students as their careers progress. Nevertheless, the study shows that a gender pay gap for graduates exists one, three, five and ten years after graduation across different cohorts (Table 1).

Table 1: Median earnings by gender, one, three and five and ten years after graduation. Source: Department for Education (2018).

Years after graduation Median Earnings (£) Difference

(% female earnings)

Female Male
One

(2013/14 cohort)

18,300 19,900 9%
Three

(2011/12 cohort)

21,800 24,200 11%
Five

(2009/10 cohort)

24,500 27,800 13%
Ten

(2004/05 cohort)

27,100 35,100 30%

 

It has been argued that part of the reason for this gap can be found in differences in the subject areas that men and women choose to study at university; women are generally over-represented in the arts, social sciences and humanities but underrepresented in the STEM subjects (Machin and Puhani, 2003; Grove, Hussey and Jetter, 2011; Davies et al., 2013). Since STEM degrees tend to lead to more financially lucrative careers, it is believed that this difference feeds into the gender pay gap (Machin and Puhani, 2003; Chevalier, 2007; Grove, Hussey and Jetter, 2011; Davies et al., 2013).

In the UK, the underrepresentation of women in STEM subjects is confirmed by an analysis of higher education statistics (Figure 2). Recent data shows that male students outnumber female students in every STEM subject apart from those associated with life sciences. Furthermore, female students outnumber male students in almost all subjects associated with the social sciences, humanities and the arts (HESA, 2018).

figure 2

Figure 2: Relative numbers of students by gender in each subject area for 2016/2017. Source: HESA, (2018)

Further data from the LEO survey shows that, ten years after graduation, those who studied medicine, economics, mathematics, engineering and technology, and architecture, building and planning, were able to achieve the highest graduate earnings (Department for Education, 2018). Of these five areas four were either pure STEM subjects or included a significant STEM component and all were male-dominated fields (HESA, 2018). Conversely, the lowest earnings were achieved by graduates of the creative arts, agriculture, education, psychology and mass communication (Department for Education, 2018). Of these five areas only psychology is a STEM subject and all are female dominated fields (HESA, 2018).

These findings have been used to suggest that policy makers need to consider the influence of the educational choices of men and women – particularly with regard to STEM subjects – when considering how to promote gender equality in earnings (Machin and Puhani, 2003; Davies et al., 2013). Such authors have supported this argument through use of the economic theory of human capital.

Human capital theory

Human capital theory asserts that a worker’s earnings are directly related to their human capital investments in the labour market and education. According to this model, a worker who makes greater investments in factors such as work experience or education and training should expect to attain higher wages than those with lower levels of investment (Becker, 1962; Blinder, 1973). Proponents of the theory suggest that this helps to explain the gender pay gap. Firstly, it has been noted that women tend to make lower investments in the labour market, as they are more likely to experience interruptions to their careers or work part time (Goldin and Katz, 2008; Bertrand, Goldin and Katz, 2010). Furthermore, as previously highlighted, they make different investments in their education – by studying different subjects. Factoring these variables into an individual’s stock in human capital, leads to the argument that men enjoy greater economic benefits because of these differing choices (Blinder, 1973; Oaxaca, 1973). However, along with this explained gap in earnings, economists note that there may be an additional, unexplained gap that cannot be attributed to one of these factors. This further gap, they suggest, represents discrimination (Blinder, 1973; Oaxaca, 1973). Thus, the explained gap plus the unexplained gap represents the gender pay gap (Figure 3).

figure 3

Figure 3: A schematic representation of the gender pay gap.

 

Consequently, human capital theory has been used as a framework to consider how the degree subject choices of men and women effect their earnings (Machin and Puhani, 2003; Chevalier, 2007; Grove, Hussey and Jetter, 2011; Davies et al., 2013). Commentators argue that as men make investments in subjects which provide a greater financial return, they maximise their expected wages. Whereas women are more likely to make investments in subjects that will lead to lower rates of pay (Machin and Puhani, 2003; Chevalier, 2007; Davies et al., 2013). This approach, however, has weaknesses; by making a distinction between the explained and unexplained gap, proponents of human capital theory have failed to understand that the factors contributing to the explained gap may themselves be subject to discrimination (England, Allison and Wu, 2007; Lips, 2013). For example, due to an unequal division of childcare responsibilities, women may be more likely to make investments in areas of the labour market that accommodate them at the cost of lower pay (Dias, Joyce and Parodi, 2018). This issue was recognised by economist Ronald Oaxaca who noted that one of the limitations of human capital theory is that “it does not take into account the feedback from labour market discrimination on the male-female differences in the selected individual characteristics” (Oaxaca 1973, p.708). Encouraging more women into STEM fields may not, therefore, be a straightforward solution in helping rectify the gender pay gap. To examine this further I will consider the experience of Malaysia and discuss the consequences of government policies that have been deliberately structured to encourage more women into STEM fields.

More women in STEM: The experience of Malaysia

Since the late 1960s successive Malaysian governments have pursued a range of interventionist policies aimed at fostering industrialisation and economic growth (Osman and Shahiri, 2014). Consequently, Malaysia has moved from being a low-income agriculturally dependent economy to being “one of the most rapidly developing economies in the world” (The World Bank 2007, p.8). Government investment in education, higher education and particularly in STEM education has been a key factor in this transformation (Ministry of Education Malaysia, 2016; Wan, 2018). As part of this drive for economic development the role of Malaysian women has been vital. Prior to its economic transformation female participation in the workforce was low, just 37.2% in 1970 (Nagaraj et al., 2014). With industrialisation, however, women’s labour came to be viewed as an underutilised resource and thus, successive governments initiated policies to harness it (Elias, 2011). In 1989 the Malaysian government formulated its national policy for women, with the aim of engaging women in the economic development of the nation (Economic Planning Unit Malaysia, 1991; Nagaraj et al., 2014). This was built upon in the 1990s, through a recognition of the economic role of women, in the Sixth Malaysia plan (Economic Planning Unit Malaysia, 1991; Nagaraj et al., 2014). More recently the Ministry of Education has outlined its strategy for encouraging women into STEM fields (Ministry of Education Malaysia, 2016). Such strategies have led to an increase in female participation in the workplace, rising to 51% in 2017 (World Bank, 2017), and with it women’s participation in higher education has also flourished.

An analysis of higher education statistics shows that in 1980 women accounted for 38.5% of the tertiary student population in Malaysia. By the year 2000 the proportion of women in higher education marginally surpassed the number of men and by the year 2015 this gap had grown such that the proportion of women in tertiary education exceeded 55% (World Bank, 2018). The data shows that these figures compare similarly with changes to the student population in the UK (Table 2).

Table 2: Percentage of students in tertiary education who are female (%) Source: (World Bank, 2018)

1980 1990 2000 2010 2015
United Kingdom 36.5 47.6 53.9 56.6 56.1
Malaysia 38.5 51 55.2

 

However, whilst participation rates may be similar, data shows that the degree subject choices of women in both countries differ. In recent decades the Malaysian government has encouraged participation in STEM subjects across the student population and has targeted female students through a variety of initiatives. For example, the highest attaining secondary school pupils, most of whom happen to be girls, are now automatically placed onto a STEM focussed curriculum (Ministry of Education Malaysia, 2016). Consequently, higher education statistics from 2013 show that, in contrast to the UK, the number of female students outnumbered the number of male students in all STEM subjects except for engineering (Table 3). However, even in engineering women still constituted 36.5% of the student population compared with just 17.5% for engineering and technology (combined) in the UK for 2017 (HESA, 2018).

Table 3: Students enrolled in Malaysian public universities by field of study 2013. Source: Ministry of Education 2014 (Cited by Wan, 2018 p.224).

Field of study Total enrolled Female enrolled % Female (vs. % male)
Science and Mathematics 48,591 33,479 68.9
Information technology and communications 30,586 16,276 53.2
Engineering 87,247 31,866 36.5
Manufacturing, processing and technology 18,259 10,582 66.3

The expansion of higher education, a focus on the education of women, and the promotion of STEM subjects appear to have done much to reduce gender inequalities in the Malaysian labour market. For example, as noted above, female participation in the workplace has grown significantly. Furthermore, government statistics show that in recent years Malaysia has been able to achieve a low gender pay gap, especially when compared with economies such as the UK (Figure 4). The extent to which Malaysian statistics can be compared to OECD calculations of the gender pay gap in the UK may be limited due to differing collection methods. Nevertheless, commentators suggest that this data shows that strategies to encourage women into STEM fields have reduced gender pay inequality in Malaysia (Strauss, 2018).

 

Figure 4: Gender pay gap in the UK and Malaysia 2012-2017. Source: (Department of Statistics Malaysia, 2013, 2014, 2015, 2016, 2017; OECD, 2018c).

However, these figures may fail to give a full account of the Malaysian experience. The following data shows that whilst for younger women the pay gap is low – indeed on average women in the 25-40 age range earn more than men – for older women the gap is much greater (Figure 5). This suggests that whilst younger women are able to capitalise on their investment in education, this advantage begins to reduce once women reach their mid-thirties and is completely eradicated and even reversed later in their careers.

Gender graph
Figure 5: Gender pay gap in Malaysia by age group, 2013-2017. Source: (Department of Statistics Malaysia, 2013, 2014, 2015, 2016, 2017).

It has been argued that this is mostly due to the persistence of traditional gender roles in Malaysia, with women often undertaking caring roles in addition to employment. Goy and Johnes (2011) suggest that this factor along with a lack of affordable childcare and a dearth of company policies on flexible working has resulted in women being less likely to take on senior positions later in their careers. Therefore, the Malaysian example shows us that whilst female investments in STEM education may promote an initial reduction in the gender pay gap, this reduction may be short-lived if women operate within a system which prevents them from making long-term investments in the workplace. These assertions have been supported by other authors who also note that once they have children women in Malaysia are much more likely to leave the labour force completely (Elias, 2011). The Malaysian government recognises these problems and is seeking to remedy them through a range of policies such as encouraging flexible working practices and improving accessibility to childcare (Economic Planning Unit Malaysia, 2015).

When comparing the Malaysian experience to the situation in the UK it should be noted that levels of female participation in the workforce are much greater in the UK (World Bank, 2017). Consequently, a simple comparison of the gender pay gap does not demonstrate how Malaysian women are more likely to be completely absent from the workforce and thus unaccounted for in gender pay statistics. Therefore, a comparison of data between Malaysia and the UK is limited. However, when considering UK policy, and the extent to which the gender pay gap may be reduced by encouraging more women into STEM fields, the Malaysian experience serves as an interesting example.

Consequences for policy in the UK

The Malaysian example would indicate that encouraging more women to study STEM subjects does not automatically translate into long term economic advantage for women. Indeed, it demonstrates that despite achieving better educational outcomes, pay and opportunities for women are constrained by a system which limits their capacity to make equal human capital investments in the workplace. Commentators have suggested that women in the UK face similar barriers. For example in the UK it has been noted that an unequal division of childcare responsibilities often results in women moving away from jobs that provide higher wages and towards jobs that provide other benefits such as flexibility (Dias, Joyce and Parodi, 2018). Furthermore, it has been argued that within the context of male-dominated STEM industries such as engineering, IT or construction that these challenges are even more profound. Research in these sectors indicates that inflexible working practices are common and career breaks are viewed negatively. Consequently women are often side-lined into lower status jobs later in their careers (Watts, 2009; Herman, 2015; Kirton and Robertson, 2018). These assertions are supported by data from the LEO survey which shows that ten years after graduation female STEM graduates in the UK earn 15-23% less than their male counterparts (Table 4).

Table 4: Gender wage differentials for STEM graduates ten years after graduation. Source: (Department for Education, 2018)

Male wages 10 years after graduation (£). Female wages 10 years after graduation (£). Female wages as a % of male wages
Biological Sciences 33,000 28,000 85
Physical Sciences 35,600 28,800 81
Mathematical Sciences 43,900 35,700 81
Computer Science 35,700 27,800 78
Engineering and Technology 41,000 31,500 77

Nevertheless, it could be argued that encouraging a higher proportion of women into STEM fields may help to promote cultural change within these sectors, which could in turn reduce the gender pay gap. However, it has been suggested that when women enter male-dominated industries in significant numbers that this leads to a reduction in rates of pay (Cain Miller, 2016). Evidence to support this shows that when women move into a sector, the perceived status of jobs in that field reduces. Consequently, men within that sector negotiate new roles, which become higher status and better paid than the roles now fulfilled by women (Lips, 2013; Goldin, 2014). Examples of this can be found in longitudinal studies in the US (England et al. 2007) and Europe (Murphy and Oesch, 2014).

Taken together, the evidence suggests that encouraging women into male-dominated STEM fields may not be sufficient to bridge the gender pay gap. When looking at examples of other countries in the OECD which have succeeded in reducing their gender pay gap, none of them have achieved this through an integration of women into STEM fields. For example, Belgium has seen one of the most dramatic reductions in its gender pay gap moving from 13.6% in 2000 to 4.7% in 2015 (OECD, 2018a). This has been achieved mostly through strategies which seek to negate structural inequalities in the working environment. For example, collective bargaining has been strengthened, meaning that gains made apply equally to both men and women, and gender-pay-gap reporting has been made mandatory (Stone, 2018). Other countries with lower gender pay gaps have instituted a range of policies aimed at tackling structural gender inequalities such as improvements to pay transparency (Norway; Collinson, 2016), mandatory paternity leave (Sweden; Jackson, 2015), and mandatory employer certification of pay parity (Iceland; Henley, 2018). It is interesting to note that in these countries the emphasis has been on tackling structural inequalities in the workplace rather than targeting individual investments in education and the labour market.

Conclusion

Following an analysis of data from both the UK and Malaysia and a review of the academic work in the area, I would suggest that human capital theory only provides us with a limited understanding of the gender pay gap and how it can be tackled through changes to education policy. Commentators who use this theory as a framework fail to acknowledge that changes in individual investments do not take place within the context of a gender-neutral environment. As previously discussed, individual investments are subject to the constraints of the system in which they are made and these constraints may not be the same for everybody. Therefore, as has been seen in Malaysia, encouraging women into STEM education may reap short term benefits regarding gender pay equality but long term benefits may only be possible with structural changes to the employment system.

There are, of course, other reasons why it could be desirable to encourage more women into STEM fields. Since the year 2000 the government has shown concern over the UK’s ability to improve productivity within an increasingly technical global economy (National Audit Office, 2018). Within this context the National Audit Office highlighted the need to encourage more women into STEM education as it argued that women represent “a pool of potential STEM-skilled people that is currently being lost to the economy” (National Audit Office 2018, P.26). Therefore, encouraging more women into STEM could be regarded as an important step towards ensuring future economic prosperity. However, for women to enjoy an equal stake in this prosperity it will be necessary for the government to tackle systemic constraints on the ability of women to invest in the workplace on equal terms with men.

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Observations and Reflections on my First Year Placement

Adrian Bloxham.pdf

This essay was written by Adrian Bloxham and was the winning social work entry in this year’s Critical Writing Prize 2019. Adrian is studying for an MA at Anglia Ruskin University and he was nominated by his lecturer Dr Wendy Coxshall.

I am currently on placement in a Supported Housing Hostel for adults in Cambridgeshire. This assignment is based on my work with one particular resident who I will refer to using the pseudonym ‘Alice’. The case study will explore core social work tenets including relevant knowledge and skills, critical reflection, processes of oppression and discrimination, communication and partnership working. I will seek to examine and reflect on my interactions with Alice, primarily by applying a reflective model to a ‘critical incident’. I will also attempt to view Alice’s life, and my professional relationship with her, from a broader social work perspective.

My initial observations and impressions of the hostel were largely defined by the levels of socio-economic deprivation that dominate many of the residents’ lives. In virtually all cases the people that live at the project either have an underlying mental health condition or experience drug or alcohol misuse, often there are a combination of these factors. The very nature of this type of accommodation means that the population is transient.  This often means that residents have little consistency and no control over who they live with, resulting in an enforced togetherness that can lead to feelings of insecurity, anxiety and fear (Bengtsson-Tops, et al., 2014). I observed during my early conversations with Alice that she often seemed subdued and that her mood fluctuated unpredictably. As the initial phase of my placement progressed I became increasingly aware of Alice’s persistent and chronic low self-esteem and her tendency to depressive episodes. I noted this in my journal and tried to “…think, to be self-aware and to question…” as a first step towards reflecting on practice (Rutter & Brown, 2012, p. 30).

My vague sense of unease and concern about Alice and her general well-being crystalized early one morning as I arrived at work to find Alice upset and in tears in the communal lounge. I now recognise the ensuing conversation as a ‘critical incident’ that changed my learning and the way that I thought about the staff and my placement setting. What qualifies as a critical incident is not rigidly defined but the event should be important or significant in some way to the practitioner and should offer the opportunity for professional learning (Fook & Gardner, 2007, p. 77). During the course of this exchange Alice disclosed to me that she felt trapped, bullied by a member of staff and other residents, and that she was feeling utterly powerless with no hope of moving on from the hostel. Alice showed me a scar on her right wrist and stated that she had tried to commit suicide in the past and was now experiencing suicidal ideation once again.

This type of situation, with all its complexities and difficulties, is described in the seminal work of Schön (1983) as the ‘swampy lowlands’ of practice (Schon, 1983). In more recent times ‘reflective practice’ has been developed further into a concept of ‘critical reflection’ (Payne, 2014). The application of critical reflection challenges accepted modes of thought, social organisation, dominant discourses and assumptions (Graham, 2017; Savaya & Gardner, 2012; Thompson, 2010). The two-stage reflective model developed by Fook & Gardner (2007) seeks to examine power relations and structures of domination, which in turn intrinsically challenges oppressive and discriminatory thought processes and practice (Graham, 2017, p.49; Fook, 2012, p.47). As will become apparent, forms of oppression and discrimination are a vital aspect of Alice’s narrative, and for this reason I propose to apply Fook & Gardner’s (2007) model to my critical incident and the subject of my case study.

Alice’s disclosure was deeply concerning and very challenging for a number of reasons. My inexperience, the fact that Alice has a diagnosis of schizophrenia and the gravity of what she was saying all contributed to a feeling of unease. The first ‘stage’ of the reflective model is designed to question the underlying structural and social assumptions of the practitioner and analyse how and why feelings of discomfort and concern have been generated (Fook & Gardner, 2007, p.92). Adopting this process has helped me to identify possible assumptions that I suspect I may have held. For example, could my knowledge of Alice’s dysfunctional relationships in the past have resulted in me making assumptions about inherent personality ‘traits’? Did I view her mood swings and depression as simply emanating from her diagnosis of schizophrenia? Did my upbringing, that instilled and encouraged a deference to authority and ‘professional’ figures, blunt my critical faculties in relation to the ‘care’ and ‘support’ offered by individual staff members? It would also be remiss to discount the influence of gender and class on the assumptions I may have held. A closer critical analysis of the factors and experiences that have shaped Alice’s life expose the fundamental flaws and prejudices in my misplaced assumptions.

As I began to work with Alice it became increasingly clear to me that she had experienced discrimination and oppression throughout her life. I learnt that Alice had endured severe and multiple adverse childhood experiences. Both of her parents committed suicide, she was raped and endured physically abusive relationships with two consecutive partners. This culminated in Alice being admitted to various psychiatric institutions in order to treat her schizophrenia and personality disorder. Eventually Alice became homeless, living on the street and addicted to heroin. The physical scars on Alice’s body as a result of these experiences can be understood from a postmodern perspective as embodied manifestations of power and oppression (Tangenburg & Kemp, 2002). Taking a postmodern perspective that conceptualises the body as the site of power relations (Foucalt, 1977) leads to an understanding that “…the body is fundamentally implicated in mechanisms of domination and control.” (Tangenburg & Kemp, 2002). Postmodernism rejects overarching general theories, instead adopting an approach that acknowledges individual narratives, social context and recognises multiple identities that may intersect (Graham, 2017; Fook, 2012). The intersection of Alice’s gender, her adverse experiences both as a child and as an adult, her diagnosis of schizophrenia and the fact that she has experienced poverty for the entirety of her life has led to oppression and discrimination at multiple levels.

A reliance on members of staff who are experienced as oppressive reinforces feelings of hopelessness, stigma, discrimination and disempowerment (Williams, et al., 2015). Alice has been exploited by fellow residents who target her on the days when she receives benefits, this form of oppression takes place at a personal level and is often experienced by adults with serious mental illnesses in the “…forced intimacy of supportive housing.” (Forenza & Bermea, 2017). Oppression and discrimination also takes place at a wider level. People diagnosed with schizophrenia are often stigmatized by a discourse of ‘otherness’ which portrays people with mental health challenges as a ‘problem’ who must be ‘controlled’ by bio-medical, biogenetic models (Beresford & Wilson, 2002). Despite the dogged insistence of the dominant ‘medical model’ discourse, contemporary evidence points to a causal link between social factors and a diagnosis of schizophrenia (Read, 2010). Typical triggers include poverty, adverse childhood experiences, rape and physical or psychological violence (Read, 2010; Burns, et al., 2014). It is essential that social workers acknowledge this increasingly influential discourse which suggests that schizophrenia and other forms of mental illness are bio-psycho-social manifestations of social conditions and health inequalities, not an inherent physiological condition (Bywaters, 2015; Karban, 2017; Friedli, 2009; Marmot, 2010; Read 2010).

Revisiting the assumptions that I outlined above has helped me to explore how I experienced the initial incident. Firstly, I now believe that I saw and understood the situation in simplistic, binary terms. Identifying assumptions and binary thinking, regardless of how uncomfortable this may be for the practitioner, is crucial and demonstrates reflexivity (Fook, 2012, p.107). By ‘deconstructing’ and ‘resisting’ this binary thinking the practitioner can then go on to address how change might be achieved and what values and assumptions have been challenged (Fook & Gardner, 2007). Arriving at an understanding of the multiple levels of oppression and discrimination that have shaped and distorted Alice’s life has not only heightened my awareness in this particular case but it has also changed the way I will approach practice situations in the future. The importance of recognising multiple perspectives and social contexts in a non-linear, fluid and multifaceted way leads to more ‘bottom up’ practice that in turn empowers marginalised people by recognising and legitimising their experiences and voice (Fook, 2012; Graham, 2017; Parton & O’Byrne, 2000).

Alice’s deteriorating mental health led me to conclude that her social worker needed to be informed of the situation. The worker expressed a great deal of frustration at the lack of inter-agency communication, written or otherwise, and a failure to disclose key pieces of information. This can often be attributed to a defensiveness on the part of housing organisations “…due to fear of damaging reputation…or fear of over-reaction” (Parry, 2013, p.19). As a plethora of Serious Case Reviews illustrate, clarity of inter-professional and interagency communication is vital for safe practice (Moss, 2017; Hall & Slembrouck, 2009; Flynn, 2010). In the case of Alice there are three primary agencies involved. In addition to this, Alice also has contact with a psychiatrist and regular medical reviews with her GP. The number of professions and agencies involved with this single client illustrates the multiple points of contact and potential challenges that operating in this contemporary inter-agency environment presents.

Understanding the communication process requires an acknowledgement of the complexity and meaning of language itself. That is to say, ‘communication’ is not neutral and does not necessarily have a universal meaning to each element of the agency or profession (Hall & Slembrouck, 2009). ‘Communication’ can be seen as a process whereby “…information passes from one person to another and is understood by them.” (White & Featherstone, 2005, p. 214). This rather simple statement camouflages the multi-layered nature of the exchange which involves an array of subjective attitudes and feelings which are projected onto the communicated information both from the perspective of ‘sender’ and ‘receiver’ (Sarangi & Slembrouck, 1996). The diversity of roles within Alice’s network highlights the danger that various professions and agencies may assign different levels of priority or even conceptualisations to the arising issues (Hudson, 2015). This means that each communication is potentially ‘categorised’ differently and therefore there is a danger that co-agencies conceive of a given situation in completely different ways (Hall & Slembrouck, 2009).

I continued to learn more about Alice’s life over the following weeks.  I observed the patience and empathy that Alice’s social worker demonstrated during the interview process. Often Alice would experience what appeared to be moments of psychosis during which she seemed to be transported back in time to a particularly traumatic event which resulted in repetitive phrases and sentences being used to describe what had happened. Although these moments appeared to be traumatic for Alice she said on many occasions that she wanted to speak about her past. I noted the way that Alice’s social worker handled difficult or emotionally salient passages during interviews (Goss, 2011), particularly the use of silence and the importance of being patient rather than asking superfluous questions to fill uncomfortable pauses (Trevithick, 2012). The importance of ‘iatrogenic health’, the process whereby possibilities and opportunities are acknowledged and explored, is part of a constructive narrative approach founded on a postmodern perspective (Parton & O’Byrne, 2000). The whole thrust of the conversations, whilst acknowledging the trauma of the past and the difficulties of the present, were very much focused on the aim of Alice moving-on in both a literal and metaphorical sense. The social worker talked through the steps that needed to be taken by Alice and the support that she would need in order to achieve this goal, a process referred to as the amplification of personal agency (Parton & O’Byrne, 2000, p.60).

This relationship-based work (Woodcock Ross, 2011) with Alice highlights the importance of partnership working and emphasises the need to avoid ‘top-down’ structural models (Hudson, 2015, p.102). Whilst the idea of ‘partnership’ suggests equality and collaboration, practitioners should still manage power relations with service users carefully, especially where a lack of confidence inhibits the service user from taking on the responsibility of partnership (Dalrymple & Burke, 2006). This aspect of partnership practice was and is very pertinent in the relationship between Alice and her social worker. The asymmetry between the social worker and service user emphasises the need for the practitioner to be cognizant of the inherent power imbalance in the relationship (Leung, 2011). Even where social work is undertaken with the best of intentions, for example in anti-oppressive practice, there is a danger that the voice and knowledge of the service user is lost by the intervention of the ‘expert’ practitioner (Wilson & Beresford, 2000).

The difficulties Alice experienced at the hostel which culminated in such a troubled state of mind calls into question the place of adult safeguarding both within the organisation and in the wider context. The implementation of The Care Act 2014 introduced new responsibilities and statutory duties on local authorities and partner agencies with an emphasis on moving away from process-driven practice (Cass, 2015). The new legislation was adopted into Company policy, statutory guidance makes it clear that there is an onus on employers to ensure that staff working in a housing environment are adequately trained in recognising signs of abuse or neglect, which includes self-neglect under the terms of The Care Act 2014 (Department of Health, 2014). At the time of my critical incident Alice was failing to attend to personal hygiene on a regular basis, frequently appeared to be experiencing low mood and would often break down in tears even when engaging in mundane, everyday conversation. Supported housing is often regarded as a positive environment that promotes recovery-oriented practice (Harvey, et al., 2012), but it can also be experienced as an oppressive and hostile setting where staff are at best indifferent to the needs of service users or can actively act as the oppressor (Bengtsson-Tops, et al., 2014). This is especially concerning when one considers that housing staff may be the only service that residents have contact with (Cass, 2015).

Risk assessments are an integral aspect of work with vulnerable people (Parry, 2013). Yet risks remain, in essence, unpredictable phenomena that defy reliably accurate outcomes (Munro & Rumgay, 2000). From a postmodern perspective, practitioners should not seek to totally eliminate risk by a ‘scientized’, calculated approach because this is doomed to failure (Parton, 1998, p. 23). Instead, there should be an acceptance that uncertainty and complexity are inherent in human interaction and therefore consideration should be given not only to ‘negative’ risk but also to the benefits of ‘positive’ risk (Macdonald & Macdonald, 2010). Risk management can be seen as a continuum (Nolan & Quinn, 2012), so whilst service user vulnerabilities must be taken into account when assessing risks there is also a balance to be struck. Planned risk-taking can and should promote a good quality of life, develop new skills and expand life experiences (Barry, 2007). Alice wishes to live independently and this is the preferred option for the social worker. However, a judgment will ultimately need to be made as to whether the rights and needs of a vulnerable service user are best served by advocating for Alice’s wishes or actively encouraging another course of action that is ‘safer’ for Alice (Kemshall, et al., 2013).

This case study has demonstrated the complexity and breadth of contemporary social work. Whilst there is not universal agreement (Ixer, 2016), the central importance of critical reflection to the profession of social work is widely accepted (Thompson, 2010, p. 183). The opportunity to work with Alice has provided much to reflect on and learn from. My work with Alice has taught me many things, most notably the impact of personal and structural processes of oppression and discrimination. However, I believe the key lesson that I take from my professional relationship with Alice is to try and show the same level of astonishing resilience and generosity of spirit that Alice has demonstrated throughout her life to the present day.

Works Cited

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Leung, T., 2011. Client Participation in Managing Social Work Service-An Unfinished Quest. Social Work, 56(1), pp. 43-52.

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Macdonald, G. & Macdonald, K., 2010. Safeguarding: A Case for Intelligent Risk Management. British Journal of Social Work, 40(1), pp. 1174-1191.

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Sample Chapter 5: Applying law in practice

The final extract from ‘Innovations in Practice Learning‘ is taken from Chapter 5: ‘Applying law in practice: Weapon, tool, manual or barrier?’ written by Allan Norman.

It’s not all about law: Let’s not kill all the lawyers

An understanding of law is compulsory for the social work student. The requirement has arisen out of historic concerns arising out of research (Ball et al, 1988) and service failures, that social workers have failed to demonstrate an adequate understanding. When the Diploma in Social Work was introduced, legal knowledge was the one area where there was specific and detailed guidance about what should be covered and how it should be assessed (CCETSW, 1995). Recent social work standards documents explicitly refer to the requirement to have an understanding of the law.

In particular, the Standards of Proficiency for Social Workers in England (HCPC, 2017) require at Standard 2 that social workers are ‘able to practise within the legal and eth- ical boundaries of their profession’, which includes the following:

2.1 understand current legislation applicable to social work with adults, chil- dren, young people and families

  • be able to manage and weigh up competing or conflicting values or interests

to make reasoned professional judgements

  • be able to exercise authority as a social worker within the appropriate legal and ethical frameworks and boundaries
  • understand the need to respect and so far as possible uphold, the rights, dig- nity, values and autonomy of every service user and carer
  • recognise that relationships with service users and carers should be based on

respect and honesty

  • recognise the power dynamics in relationships with service users and carers,

and be able to manage those dynamics appropriately

My selection of these parts of that standard is intended to reflect that the require- ment to understand law is interwoven with an understanding of the nature of profes- sional judgement, of power and authority, of ethics, and of rights, among other things. The priority given to the different parts of this Proficiency Standard may well affect whether law becomes weaponised, seen neutrally as a tool or manual, or perceived negatively as a barrier.

The reference in the opening of this chapter to ‘authority generally, and to legal authority in particular’ reflects that when I introduce students to law, I start not with the idea of the law, but the concept of legal authority. This can convey both that it is a characteristic of law that it carries some kind of authority, and also that the law is not alone in possessing that characteristic. In turn, to view law as carrying some kind of authority invites thinking about the nature of law, and indeed critical thinking about whether and why the law should carry authority.

Rodriguez-Blanco (2014, p 11) observes:

Law transforms our lives in the most important way: it changes how we act and because of this it gives rise to fundamental questions. One such question concerns legal authority and individual autonomy and asks: if we are autonomous agents how do legislators, judges and officials have legitimate authority to change our actions and indirectly change how we conduct our lives?

This question, posed in respect of the relationship between law and the individual, takes on an added piquancy when revisited in the context of the relationship between law and social work: is social work an autonomous profession if its actions are tightly bound within the four corners of a restrictive legal framework?  Ife  (2012,    p 12) observes that the social work role manifests itself in different ways throughout the world, but that:

In societies such as that of the United Kingdom, social work has been seen as the implementation of the policies of the welfare state through the provision of statutory services …

Social work in the United Kingdom is thereby singled out as an example of a model constrained within the legislative framework and purpose. Social workers and students will need to be particularly astute to understand the framework of legal authority which governs their role.

One approach to opening up the different kinds of authority which the social work student will encounter is to consider the different types of question that might invite reflection in a practice situation. Table 5.2 introduces, alongside legal authority, some of the other kinds of questions that the law is not appropriately placed to address.

 

Table 5.2 Different sources of authority

 

Law What am I allowed or required to do?
Ethics What is the right thing to do?
Research/Evidence-Based Practice What has been observed to happen? What works?
Professional Standards and Codes What is considered professional behaviour?
Comparative Practice How is it done elsewhere?
Government Policy What does the government want me to do?
Policies and Procedures What do other people want me to do?

 

Students arriving on placement may have been taught law in a variety of different ways. In some institutions, legal knowledge and understanding is integrated throughout the course; in others, it is a discrete element of the course (Braye and Preston-Shoot, 2005, pp 23–4). In some institutions, law is taught alongside ethics (Braye and Preston-Shoot, 2005, p 66). In others – and indeed within the pages of this book – law and policy are grouped together. Sometimes, law is compartmentalised, with the law relating to different areas of social work practice separated out.

Table 5.2 invites certain reflections on the law with which the student arrives equipped on placement. If law and ethics for example are answering different kinds of question, then they might not point towards the same conclusion as to the right way for the social work student or practitioner to act. Practitioners cannot always avoid such dilemmas. Take, for example, the Withholding and Withdrawal of Support Regulations 2002. As their name hints, these regulations require social workers to withhold or withdraw social services support from certain categories of individuals on the basis of their immigration status. This is legislation, but there is good reason to think that there might be some conflict between such a legal obligation and one’s eth- ical or professional obligations. Humphries (2004) powerfully articulates that social workers operating such laws:

 

… have not resisted the gate-keeping and inhumane role thrust upon them. It is no wonder they are despised and feared by the people they purport to help. We can safely regard the rhetoric about anti-oppressive and anti-racist practice as harmless delusion.

If, however, law is no more than a manual telling you how to perform the social work role, then there might be no critical engagement between legal and other forms of authority such as professional and ethical authority.

A similar point might be made in relation to research into the effectiveness of different forms of intervention: the fact that a particular form of intervention is shown to be effective does not necessarily mean that it is ethical, nor that it is lawful.

Law and policy are so frequently elided that it might be surprising within Table 5.2 to see the suggestion that they are answering very different kinds of questions, and indeed that policies seem to be held out as having little authority. That, however, is an important point for the student to grasp. Policies and procedures play a prominent role within many agencies in shaping practice. Sometimes they are indeed conflated with the law in the practitioner’s imagination. However, the critical and reflective prac- titioner will understand that policies do not in themselves have any legal authority, and will reflect on issues of ethics, professional role, rights etc rather than turning uncritically to an agency policy as a manual determining how to act.

We hope you’ve enjoyed reading these sample extracts from ‘Innovations in Practice Learning! For more information or to purchase your copy of this book click here.

 

Sample Chapter 3: Supervision within placement

The next sneak preview from ‘Innovations in Practice Learning‘ is taken from Chapter 3 entitled ‘Supervision within placement: Achieving best practice’ by Heidi Dix.

Students may find that they have a practice educator who is based within the agency and from whom they will receive weekly supervision. However, in other placements the practice educator is not based within the agency and an on-site practice super- visor will be appointed to provide day-to-day support and guidance. Students who have an on-site practice supervisor in addition to their practice educator may find that supervision will be given on alternate weeks by the practice educator and the on- site practice supervisor. The nature and content of supervision provided within these roles is slightly different. For example, supervision with an on-site practice supervisor could focus on the direct work the student is undertaking and have more of a man- agerial focus, for example, ensuring that the student is working within the agency’s eligibility criteria. However, supervision with a practice educator may have more of an educational and reflective focus, supporting the student to apply the knowledge they are learning in university and their self-directed learning to the work they are undertaking in placement.

Below are some comments from students in relation to the advantages and disadvantages of off-site and on-site models of practice education which I have heard over the years. Of course, these are generalisations and will not apply in all situations, but it is worth noting the strengths and limitations of both models. However, the most important thing is that the practice educator and practice supervisor work together to meet the learning needs of each individual student.

 

Advantages of having an off-site practice educator and on-site supervisor Disadvantages of having an off- site practice educator and on-site supervisor
‘If practice educators are not directly working within the agency they can provide greater objectivity and support students to question agency policy, procedures and practice.’ ‘Practice educators may not have direct practice experience in the area of social work that students are placed in.’
‘Off-site practice educators often bring experience from other areas of social work, enabling students to  compare and contrast their placement with other aspects of social work practice.’ ‘Off-site practice educators are often not available outside scheduled supervision times.’
‘Off-site practice educators, particularly those who work independently, will often support a number of students and will often provide group supervision which can be beneficial.’ ‘Contact with practice educators will be limited, particularly within the 70-day placement.’

 

Advantages of having an off-site practice educator and on-site supervisor Disadvantages of having an off-site practice educator and on-site supervisor
‘Practice educators will have direct practice experience of the work required within the agency.’ ‘Students can learn from different approaches and styles, eg “two heads are better than one.”’
‘They are often available for both formal and informal supervision,’ ‘Practice educators can be immersed in the culture of the agency and could be

adverse to the student asking questions that

demonstrate critical reflection.’

‘Supervision will be offered on a weekly basis with the same person.’ ‘Students will need to ensure there are opportunities to shadow other colleagues, not just their on-site practice educator.’

 

The majority of supervision students receive will be on a one-to-one basis, although there may be occasions when group supervision is used. Students often find this helpful as it enables them to share learning with other students in a practice setting and provides another form of support (Doel, 2010). However, one-to-one sessions are critically important in enabling a student to focus clearly and in depth on issues specific to their individual learning needs, particularly if a student has additional learning needs (see Chapter 8). There are also different expectations of students in their first and final placements as they build on the capabilities demonstrated in the first placement. Although students will still be offered guidance and support in their final placement, they should be given more autonomy as their confidence and ability increases. Students often find that their learning needs change as their confidence increases and consequently require different things from supervision. For example, in early supervision sessions, students may require support to develop their self- belief. However, as students develop in confidence, they may require less of this type of support and supervision could focus more on developing critical thinking skills.

An insight into what students can expect from their supervisors and practice educators

As adult learners, Rogers and Horrocks (2010) suggest that although we will have similar characteristics we also have differing needs depending on a range of factors. These include issues of diversity such as gender, ethnicity and class as well as the level of experience, skills and knowledge that students bring to the programme. Depending on our personality types (Rogers and Horrocks, 2010), the attachment experiences we have received in childhood (Howe et al, 1999) and whether we are operating from a secure base (Bowlby, 1973), we may require more or less support in particular areas of development. Therefore, as part of supervision sessions, students can expect their practice educators to ‘tune in’ (Taylor and Devine, 1993) to their needs to assist them to identify previous skills and experience in order to assist them appropriately. Research conducted with social work students by Lefevre (2005) suggested that stu- dent learning is enhanced when students feel listened to and respected by practice educators; therefore, developing a professional relationship to facilitate effective supervision is helpful to both parties. It is important that each party understands what is expected of the other and this needs to be clarified if there is any confusion.

There are many ways that we learn and take in information. Many of us prefer to have information presented to us visually, some of us find if we hear things we retain them better, others prefer to see things written down, and some of us learn best if we can move around and utilise our senses (Fleming, 1995). For some of us, experien- cing something and thinking about it afterwards is the best way that we learn (Kolb, 1984). There are a number of questionnaires that are available to help us under- stand our learning styles (Honey and Mumford, 1992; Fleming and Baume, 2006) and it may be helpful for students to complete one of these and share the results with their practice educator to enable them to tailor their support to help maximise the student’s learning. Although we often have a preferred way of learning, it is important that we have the ability to be receptive to new ways of understanding, because as practitioners we will often work with service users who will have a different way   of learning to ourselves. We may need to present information to service users in a way that best meets their needs; practice educators may model this by encouraging students to be flexible and to begin to adopt new ways of receiving and processing information.

 

Organisations have different policies in relation to the amount of supervision to which employees are entitled. Students may find themselves placed in organisations where supervision is not something that is routinely offered to employees or volunteers. However, qualified social workers employed by a local authority are entitled to regular and consistent supervision (LGA, 2014). As social work students, the frequency of supervision will be determined by the university and negotiated with the placement provider at a Learning Agreement Meeting. In addition to formal supervision sessions, students should be able to ‘check out’ any questions they have in between sessions by utilising the experience and knowledge of other practitioners within the organisation. If students believe they are not getting the length and quality of the supervision they are entitled to as a social work student, they should be encouraged to inform their university tutor who may need to revisit this with the placement provider or practice
educator as part of the Learning Agreement.

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