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Identifying Barriers

This section will look at typical barriers to communication which might arise when a social care assessment is being carried out. To do this we'll look at the situation of Mrs Carmen Andrews, an 82 year old black woman.

Mrs Andrews is widowed and lives alone. She has no surviving children. She has been admitted to hospital following a fall. X-rays have identified that she has broken her hip. Tim Drew, the hospital social worker, has been asked to assess her future care and support needs.

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Identifying Barriers

Before we continue, take a few minutes to think about the possible barriers to communication:

Imagine the scene:

Mrs Andrews in a ward with several other patients but does have curtains that can be drawn around her bed. She wears a hearing aid and is bed bound when Tim Drew comes to see her. Tim is a white man, wearing a suit and carrying an official looking briefcase and various documents. Tim has a lot of people to see and is very busy.

Note your thoughts down and then click 'Next' to see if your thoughts correspond with ours.

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Identifying Barriers

Listed below on the areas we think might cause barriers. Click on each item to see a detailed explanation of our thoughts.

Identifying Barriers

Interpersonal dynamics

The relationship that forms between worker and service user or carer lies at the heart of effective social work practice (Trevithick, 2003; Lefevre, 2008).

If Mrs Andrews feels Tim is not interested in her worries or unable to manage her feelings she is likely to clam up. If he seems distant and professionalised rather than personal and human she is unlikely to want to confide in him. She may even become anxious and nervous of him and struggle to express herself clearly. Tim will then be less likely to make an accurate assessment.

Tim will need to form the kind of engagement with Mrs Andrews which enables her to feel sufficiently safe and trusting with him that she can share her deepest concerns and explore what her needs are.

Identifying Barriers

Role and Task

Tim has a clear role and task in this situation. He must carry out a social care assessment to determine whether Mrs Andrews can return home safely (and if so, what supports she will need) or whether she needs to move to some form of residential care or sheltered housing. The assessment needs to be completed quickly to free up Mrs Andrews' hospital bed (Local Authorities may be fined where they have caused unnecessary delays).

In what ways do you think the quality of Tim's communication skills will affect the accuracy and depth of the assessment information gathered?

Identifying Barriers

Role and Task

Mrs Andrews is quite nervous about what she says to Tim because of his role. She wants to return home but knows she will need quite a lot of help to do so. She is worried that if she explains all the different kinds of help she needs that Tim will think she can't manage at home and will insist she moves to residential care. Consequently she gives quite a muddled narrative and Tim starts feeling very confused.

Tim realises he has to begin by explaining clearly how and why he needs as much clear information as possible. He needs to spend time putting Mrs Andrews at her ease so she feels sufficient trust to confide her concerns to him. She is then more likely to give him a clear and consistent picture of her situation and needs.

Identifying Barriers

Professional Identity

The way that workers present themselves within their role has an effect on how powerful and competent they seem to others. How workers think and feel about their professional identity will affect how they portray themselves.

Tim has turned up for work today dressed in a suit and tie and carrying a briefcase. He does this because he is a little uncertain about how authoritative he appears in his role. Working as part of a hospital multi-disciplinary team he feels rather intimidated by hospital consultants and dresses more formally to feel more confident with colleagues and service users. This makes some service users feel more confident in his professional authority. However, Mrs Andrews feels rather intimidated by his appearance.

For Tim, then, his professional identity is bound up with issues of confidence, power and status. He feels more authoritative approaching Mrs Andrews with his professional persona to the fore, rather than his real human self.

Mrs Andrews is not alone feeling rather uncomfortable with this. Many service users and carers prefer a social worker who can approach them as one human being to another, real, open, warm and genuine (Lefevre, 2008). This does not mean breaking boundaries or trying to be a service user's friend, but developing a professional identity which is congruent with the worker's real feelings and personality. For Tim this will mean recognising and managing his anxieties and lack of confidence rather than hiding behind a professional 'mask'.

Identifying Barriers

Time

Tim is worried about time as he arrives to meet Mrs Andrews. He has a number of assessments to complete this afternoon and has only about 25 minutes to engage Mrs Andrews in what is likely to be a very difficult conversation about her future social care needs and whether it is safe enough for her to continue living at home.

Mrs Andrews will respond most effectively if Tim creates a safe and relaxed atmosphere in which she feels safe to share her history, needs and concerns (Moffat, 1996). Trying to rush her could well be counterproductive but there are very real constraints regarding his time and the need for her to move on from her hospital bed.

How might Tim best manage this?

Identifying Barriers

Time

Tim should be clear about the amount of time he has and ideally should negotiate with Mrs Andrews about this, e.g.

  • 'I have about 25 minutes until my next appointment. Would that be enough time to begin to look at what's happening to you?'

If the information required is urgent, then Tim should be realistic and transparent about this, e.g.

  • 'I realise that this might not feel ideal but we need to gather the information today in order to begin to make plans for your care'.

Once Mrs Andrews begins talking she may not be aware of the time so Tim will need to give her a clear cue for the ending approaching and ensure her biggest concerns have been mentioned, e.g.

  • 'As we only have a couple of minutes left, I wanted to check if there is anything important you haven't yet told me'.

Identifying Barriers

Territory

Territory refers to the space or environment in which the communication takes place (McLeod, 2007).

Tim is visiting Mrs Andrews in a busy hospital ward. She is lying down in a bed. There are some curtains but they are not drawn. Consequently there is very little privacy. It is likely other patients, visitors and staff will hear very personal details. Mrs Andrews may feel very reticent about talking about her needs and difficulties in such circumstances. This is clearly far from ideal.

What could Tim do in this situation to overcome the territory barriers to communication?

Here are some possible options. Consider the pros and cons of each one.

Tim could

  • Draw round the curtains
  • This might be helpful so that at least there is some visual boundary and privacy from others. However, drawing the curtains should be negotiated with Mrs Andrews as she might feel vulnerable closeted with a male stranger when she is dressed only in a nightdress.

  • Speak in a quiet voice
  • This could help ensure that others are less likely to hear but Mrs Andrews may also mishear things, particularly given that she has a hearing aid. Tim will need to check out the optimum sound level.

  • Say he can't do the assessment in such an environment
  • Where it is possible to re-arrange the assessment location for a more suitable environment this would always be the preference.

    However, this may not be realistic or possible due to external pressures for assessment information to be collected and a lack of appropriate alternative venue. The constraints and difficulties of the environment should always be acknowledged to and discussed with the service user. Mrs Andrews might also have her own ideas about what might make the environment feel more conducive to her.

Identifying Barriers

Emotional and psychological issues

Mrs Andrews is feeling frightened and distressed whilst lying in her hospital bed. Tim guesses correctly that she is dealing with the here-and-now pain and discomfort of a broken hip and uncomfortable hospital environment as well as very real worries about her future. He knows how important it is to recognise and work with her emotions if he is to help her feel that he understands and appreciates her concerns. This is an important step towards her feeling safe enough to talk openly with him.

There are some other underlying issues, though, that Tim has missed so far and which affect what information Mrs Andrews conveys during the assessment. Do you have any ideas what these may be?

Identifying Barriers

Emotional and psychological issues

Tim needs also to take into account issues relating to Mrs Andrews' past experience and 'life stage' issues (Erikson, 1963).

One of the reasons Mrs Andrews is so keen to remain at home is because that is where she lived with her husband and raised her children before they all died. Her memories of them are bound up in the family home. The thought of possibly leaving there feels quite unbearable and this over-rides all her other considerations, including her safety and wellbeing. Consequently she minimises to Tim her difficulties in coping at home.

If Tim is to determine whether or not home is actually safe for Mrs Andrews he will need to recognise and help Mrs Andrews work through her feelings of loss so that she can be more open about her difficulties in self-care.

Tim needs also to appreciate Mrs Andrews' existential (These are the problems of meaning and existence all humans face such as who am I?', Why am I here?', 'What happens when I die?') concerns which are related to her life stage. He is still quite young himself, his parents are only just at retirement age and his grandparents died when he was quite young, so he has had limited personal experience and understanding of what ageing and death can really mean for people.

For Mrs Andrews, breaking a hip at the age of 82 means really having to confront her own mortality. She is having recurrent intrusive fears about being disabled and at the mercy of others, and about death and how and where she might die. Partial denial of her physical difficulties gives her some respite from these fears but means she wants to hide from others (and maybe herself) what she might really struggle with.

Tim needs to gently and sensitively help Mrs Andrews to begin to confront and explore these issues to inform a realistic appraisal of her future care needs.

Identifying Barriers

Power

Mrs Andrews has enormous strengths gained through a range of experiences, including moving from her country of origin to Britain, marriage, being a parent, working and bereavement.

This is not apparent to Tim on his arrival for the assessment because of how Mrs Andrews presents at that time. She is feeling disempowered, unwell, worried about the future, and uncomfortably dressed in her nightclothes in the presence of a young man. She comes across to Tim as frail and anxious.

Tim struggles to appreciate how competent Mrs Andrews has been previously and might be again once she is over this crisis. He is at risk of seeing her only as a frail, elderly woman in difficulties who needs care and protection.

How might this affect what Tim hears Mrs Andrews say or how he interprets it?

Tim's initial reactions may lead him to form a hypothesis that Mrs Andrews will not be able to cope on her own and needs to go into a home. He might then start to interpret everything she tells him through that lens and in support of the decision he thinks is best. He could fail to hear the information she gives which contradicts this (Munro, 1999).

Whilst Tim intends to be caring towards Mrs Andrews he may then end up using his own professional power to disempower her further.

What should Tim do to stop this happening?

Identifying Barriers

Power

Tim needs to adopt an anti-oppressive approach to his practice, e.g.

  • Openly acknowledging the power dynamics between him and Mrs Andrews (e.g. her being in bed in her nightdress)
  • Ensuring her views are heard and taken into account in any decisions
  • Appreciating her strengths as well as her vulnerability and difficulties
  • Identifying his stereotypical views of her

This approach will improve the communication between them and mean Mrs Andrews is not disempowered further.

Identifying Barriers

Special communication needs

Mrs Andrews has a hearing aid which should signal to Tim that she is deaf or has hearing loss. However, aids are not always visually apparent and referrals to social workers might not always mention these amongst a myriad of other, more urgent, information. Aids may also become damaged or work less effectively in certain circumstances.

Tim, then, may arrive assuming Mrs Andrews can hear everything he says when, in fact, she may not. Because of her pain and distress in the current situation, too, she may not be able, or get the opportunity, to alert Tim directly to her hearing difficulties.

As part of the initial assessment, then, Tim will need to have in the forefront of his mind to check out whether there are any special communication needs, even when this hasn't already been raised.

Once Tim has understood the parameters of Mrs Andrews' hearing loss or deafness he will need to negotiate with her the best method of communication. If the hearing aid does not allow for sufficient mutual verbal communication, and he cannot use her preferred alternatives (For someone who has been deaf from an early age this might be British sign language (BSL) and an interpreter may be needed.) then other methods or supplementary methods need to be considered, e.g. written communication. Otherwise Mrs Andrews will be excluded from discussion and decision-making (Koprowska, 2008).

Identifying Barriers

Difference

Tim will need to consider whether and how any differences between himself and Mrs Andrews get in the way of him understanding what is significant for her. Religious and cultural identity are two differences which may well affect the extent to which Tim takes into account Mrs Andrews' feelings about and interpretation of her situation.

At the moment, Tim does not know whether Mrs Andrews practises a religion or, if she does, whether and how this has a bearing on the assessment. He will only find this out if he raises this with her in a sensitive and accepting way (McLeod, 2007).

Understanding how Mrs Andrews' cultural heritage and identity has a bearing on her current situation requires similar sensitivity, openness and acceptance. Tim can see obvious differences between Mrs Andrews and himself with him being white and of British origin and Mrs Andrews being black and of Afro-Caribbean heritage. He is keen to explore the possible meanings and importance of this.

But he would be mistaken only to do this with service users of a different ethnicity to himself. All people have their own cultural heritage which brings meaning and shape to their lives, and workers need to appreciate this if they are to effectively support and intervene in the lives of others.