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Section two: Collaborative working, partnership and community involvement

By completing this section of the module you should be able to:

  • to clarify terms and legislation relating to collaborative working, partnership and community involvement
  • to explore the challenges to partnership initiatives
  • to examine the practical implications of adopted collaborative working practices
  • to discuss the dynamics of advocacy and user involvement in partnership and collaborative working
  • to describe the models and processes of empowerment

Collaboration defined

There has been a variety of changes in the context of health and social care provision in the UK over the last decade. This has resulted in health care delivery moving away from the traditional acute care settings to community based settings and client's homes. The role of the multi-professional team in the provision of a person-centred, holistic patient care, which is suited to individual needs, has been the subject of many Government white papers (Department of Health, 1997, NHS and Community Care Act 1990). There has also been a requirement for health and social care agencies to work closely and collaboratively together in partnership with service users (Department of Health, 1998a, 1999a). Achievement of the goals of collaboration is dependent on co-operation replacing competition, and focusing on professional responsibility on meeting the increasing complexity of patient care (Crinson 1999).

Collaboration is a complex and multi-faceted concept with often vague or highly variable definition (Henneman, Lee and Cohen 1995) resulting in inappropriate use. The literal translation of this term from Latin is 'together in labour'. The dictionary definition of 'to collaborate with' is 'to work with another or others on a project'. However the term is often considered synonymous with other modes of interaction such as co-operation, compromise, teamwork, alliancing, joint planning, inter/multidisciplinary, multi-agency, inter-sectoral and inter-professional practices. The inappropriate use of the term collaboration leads to confusion, which may hinder the usefulness and consistency in health care practice (Baggs et al 1992) and failure to find a positive correlation between collaboration and patient outcome (Zimmerman et al 1993). Hilmmelman (1994) describes collaboration as exchanging information, altering activities, sharing resources, and enhancing the capacity for mutual benefit and to achieve a common purpose.

In practice, collaboration is diverse and varied, ranging from intra-disciplinary teams on an individual setting to multi-agency working practices, which involve joint commissioning and service planning between health authorities and local authorities and national authorities, such as education authorities, as well as private and voluntary sectors. Collaboration covers the whole process of researching, assessing, planning, implementing and evaluation

(In following this module you should routinely make reference to the complementary analysis offered in 'Section Four: Consultation' of the module Race Equality Management by Karen Chouhan and Dave Weaver).

Exercise 2.1 Self reflection activity

  • how would you define collaboration?
  • think of three situations in health care practice that you have worked within a multidisciplinary team.
  • what considerations must be made when multidisciplinary teams work with people from minority ethnic communities?

Memo

  • Collaboration can be described as the cornerstone of effective community care.
  • Effective collaboration between users and staff is the key to successful multi-professional and multi-agency work.
  • Collaboration involves seeing something through in partnership from beginning to the end and beyond i.e. long term shared outcomes.

There is often an underestimation of the importance of the appropriate collaboration or partnership between health practitioner and client (Whitehead 2001). Lewis and Meredith (1998) emphasise the 'importance of equal involvement and shared ownership as part of collaborative framework'. Such partnerships offer opportunity to share and discuss actions, values and the need to produce joint policy statements. They also widen the pool of resources and skills available to provide the service needed.

Impetus for collaboration

The professional needs to apply all the tenets of good partnership which are defined by key legislation, most of which were enacted at the turn of the last century.

In 1988, the Acheson report charged the Director of Public Health with partial responsibility for assessing the collaboration of various health-related agencies and health-related activity. This provided necessary impetus for collaborative reform in primary health care. In the report Caring for people: Community care in the next decade and beyond (Department of Health 1989), the main objective of the health service is stated as 'helping people to lead, as far as possible, full and independent lives … to stimulate public agencies to tailor services to individual's needs… promote choice as well as independence".

The NHS and Community Care Act (Department of Health 1990) has transformed the relationship between the health and caring professions and their client constituency attempting to engender lasting collaboration between 'key' agencies to bring about change. However, attitudes between health and social services are typified by professional conflicts, which result from different approaches to care provision. Differences in professional ethics, accountability, standards and resources also influence the relationship. Perhaps, this informed the production of Working Together (Department of Health, 1991a). The document sought to facilitate inter-professional and inter-agency co-operation and so to enable local authorities to work in partnership with parents and children in protecting children from abuse. It emphasises the need for social services department, police, medical practitioners, community health workers, schools, voluntary organisations and any other concerned agencies to develop close working relationships.

Health of the Nation (Department of Health, 1992) has highlighted the need for collaborative practice to be incorporated into a National Health Strategy. This white paper places collaborative practice in the centre of the health service reform and defines collaboration as "…a partnership of individuals and organisations formed to enable people to increase their influence over the factors that affect their health and well being" (Department of Health, 1992). The framework offered by the Health of the Nation Strategy (Department of Health, 1992) identifies key areas for priority targeting under the reorganised health service. The collaborative ventures had to target certain high vulnerability groups in the community, such as women, certain socio-economic groups and minority ethnic groups. Targeting Practice, (Department of Health, 1993) identified aspects of good practice to be promoted within community health practice. This includes building healthy alliances within, across and beyond the health sector with a view to providing "seamless service, good communication and good working relationships' as well as shared aims and values, mutual respect between professional groups, shared learning, formalised co-ordinated strategies and organisational power.

Other legislation, which has provided the impetus for collaborative working, includes The Vital Connection (Department of Health, 2000a), NHS plan (Department of Health, 2000b) and Working Partnerships (Department of Health, 2000d). The Government in its Equality Framework (Department of Health, 2000a: 34) stresses that "the NHS must engage the active commitment of the local partners and communities in pursuing the three aims." These changes, it is hoped will remove " the outdated institutional barriers between health and social services which have got in the way of people getting the care they need when they need it." (NHS 2000b: 73).

Memo

  • government policy and legislation provides impetus for health-social service collaboration
  • ensuring seamless health and social services provision has been a concern of policy makers for many years
  • successive governments in the UK have underlined the need for collaboration and joint working in the delivery of health and social services.

Obstacles and challenges to culturally appropriate collaboration

The application of the foregoing legislative frameworks appears appropriate but it poses some challenges for all parties - the professionals and client and families, particularly for clients from minority groups. Developing the level of synergy required for effective collaborative practice is one challenge that needs considering. These challenges are shown in figure 2A:

Figure I - Challenges to culturally appropriate collaboration

Figure I - Challenges to culturally appropriate collaboration

Power imbalance between partners

A key element of any collaborative arrangement is power. Literature suggests that partnership between large organisations and the minority ethnic voluntary organisations, and indeed minority groups, is fraught with problems (Chouhan and Weaver 2000). This may result from the power imbalance between the parties involved. Large organisations have the advantage of wealth of resources, while the Black and Minority Ethnic groups present with little or no resources to compete favourably. This immediately places the Black and Minority Ethnic groups in inferior positions in any collaborative effort developed with these organisations. The balance of power needs to be adjusted towards community groups and voluntary organisations, as well as consumers of services.

The appropriate involvement of individuals and communities should not be confused with the need to promote a community's power in engaging in collaborative initiatives. If community power is not promoted as part of community participation, this may lead to disgruntlement and despair and members may feel their views are disregarded. Many problems can also result, such as the lack of knowledge about the system, difficulties in attending meetings, tokenism, and economic constraints. These problems are further compounded when dealing with individuals or community groups with language difficulties and other communication problems. This raises the issue of community members becoming 'pseudo-professionals' and being expected to deal with general needs rather than their own needs. Croft and Beresford (1989: 15-16) note "user groups are increasingly conscious of the problem of being sucked into the operational and organisational detail of agencies, when what they actually want is more control over their own lives and their dealings."

Another issue raised is the inherent assumption that any given group of users / community representatives speak for all members of the defined group. This could create some problems and needs to be managed appropriately. Professionals can actively seek to involve advocates and personal representatives and ensure Black and Minority Ethnic members / groups and their supporters are fully informed as to the process and its limitations. Creativity in using funding and finding support outside normal pathways will foster a more individualised approach to meeting needs. The community groups must be honest in themselves and to their users regarding their abilities, their limitations and their conflicts. In addition to voluntary organisations being involved in service planning, there is need to recognise the limits of this approach in striving to continuously promote the consumer's rights or power. The object is to discourage gate-keeping and integrate as diverse as possible forms of assessing and delivering services to different client groups.

You will find it useful to look at the section - 'Engaging minority ethnic groups and individuals in partnerships' in the module Ethnicity and Learning Difficulties by Ghazala Mir.

And at the discussion of 'Multi-agency Partnership Approaches' in Section One of the module Race Equality Management by Karen Chouhan and Dave Weaver.

Demographic context

By definition, partnership working should be inclusive and should bring together diverse groups. It sometimes marks the first time that historically divided groups come together to solve common problems. The diversity within the groups of collaborators can hinder or encourage inclusion and participation. Cultural and language barriers may limit participation.

Collaboration in health and social service arenas should ensure that minority groups are involved as failure to do this may give rise to tension within the alliance and may result in a lack of acceptance of the alliance by the community. Another problem, related to the creation of an alliance, is that there needs to be a full representation of the ethnic and racial composition of the community. Perceptions of inclusion may be a particular problem if the lead agency is predominantly white, middle-class and professionally led (Braithwaite, Taylor and Austin 2000). If an alliance is simply made up of a few individuals from key organisations to speak for the interest of an entire ethnic group, the proposed effort will fail to represent the diversity within the minority groups.

Even where there is cultural or ethnic homogeneity, the importance of social class in promoting and sustaining effective collaboration cannot be dismissed. For example, disagreements could arise between Africans who are economically poor, who are represented by Africans from more established communities. Some alliances dominated by middle class South East Asian businessmen may focus crime prevention upon low-income, inner city residents, whereas members who represent disadvantaged groups may feel this focus to be inappropriate because drug use and arrests frequently involve middle class, suburban residents.

Age difference between partners may also affect the success of a collaborative arrangement. Wandersman et al (1996) found disparity in perceptions about community needs and priorities, when they examined community alliances involving young, economically poor people and older, power elite, middle class residents. These disparate perceptions led to disagreements about the goals of working together.

Exercise 2.2 Self reflection activity

Identify a community - one that you live in or know. List the groups that make up this community. How is the local health or social service institution partnering with these groups? Based on your knowledge of the community, what partnerships might be important? What cultural groups may be at risk of being overlooked from these partnerships? And why?

Political and religious context

Political and religious factors can pose a significant challenge to partnership or collaborative efforts. Consideration needs to be given to the religious orientation of a community. There is need to assess the roles of different religious leaders as they are often trusted members of the community who can improve the credibility of the community involvement. Again, it means checking that individual agendas do not damage or overwhelm the needs of all members of the community. As already discussed, the members' rights or powers need to be recognised when involving representatives.

Memo

  • social and health care practitioners should strive to work in partnership with service users and to empower the citizens to be fully involved as an equal partner. This requirement often presents tensions and should be explored for contradictions for the professional and service users.
  • the root causes of inequality can be effectively tackled through integrated thinking at policy level and greater interagency co-operation in the administration and delivery of services and programmes alongside the potential for future collaboration and cross-boundary working.

Balancing power relations in partnership across cultures

Partnership is vital in promoting appropriate services for Black and Minority Ethnic service users. They sometimes experience the controlling rather than the supportive aspects of legislation. There have been varying developments and the principle of user participation has evolved; perhaps more pronounced in care involvement of people with learning disabilities, in the mental health arena and in the care of older people in residential care facilities. While the Children Act (1989) emphasises the value of partnership, a National Inspection of Services to Disabled children in 1993 found that despite evidence of much positive practice, a partnership approach was lacking (Dalrymple and Burke 1995). Partnership can mean different things to different people including what Arnstein (1969) has highlighted as non-participation, varying degrees of tokenism and user power. The central element of partnership is the notion of user involvement in all aspects of service delivery. The NHS has clearly acknowledged the need for partnership in the government's strategy outlined in The Vital Connection (Department of Health, 2000a). The health and social care services need to engage the active commitment of local partners and communities in achieving social inclusion and equality of opportunity. This can be achieved by working together with trade unions, professional bodies, community groups and local authorities, in pooling knowledge and ideas for reaching marginalised and excluded groups.

Before starting on the next part you will find it useful to read the section on 'Empowerment' in the module Ethnicity and Learning Difficulties by Ghazala Mir.

While partnership and empowerment are not the same, partnership does, and must involve a sharing of power. In elaborating the need for a statement of principles for empowering practice, Stevenson and Parsloe (1993: 39) cite a framework used by Social Work in Partnership, a project involving both children and adults based in two different local authorities. The agreed principles of the project are shown in the box below:

Principles of social work in partnership project

  1. Investigations of problems must be with the explicit consent of the potential user(s) and client(s) (a client is operationally defined as an involuntary user)
  2. User agreement or a clear statutory mandate is the only basis of partnership-based intervention
  3. Services must be based on the views of all family members and carers
  4. Services must be based on negotiated agreement rather than on assumptions and/or prejudices concerning the behaviour and wishes of users.
  5. Users must have the greatest possible degree of choice in the services they are offered.

Partnership is not necessarily based on equal power relationships. However, the practitioner has to be aware of the need to empower rather than disempower and the need to balance power relationships. There are a number of ways that partnership can be managed to promote effective relationships with individuals, groups and multidisciplinary teams. These include:

Promoting a diverse health workforce for effective collaboration

One of the aims of the NHS equality framework (Department of Health, 2000a) is: "To recruit, develop and retain a workforce that is to deliver high quality services that are fair, accessible, appropriate and responsive to the diverse needs of different groups and individuals." The first step to making services accessible to different communities is to achieve a workforce that better reflects the lives of and sections of society (Rashid 1990). This implies the ability of the health service and educational institutions to recruit and retain members of all sections of the community, and the ability of the staff to work together.

In a joint statement, the CVCP and the NHSE emphasise the partnership role of the NHS and the HE in:

  • developing awareness of what careers in the NHS can offer to the whole of the community
  • nurturing skills of the potential workforce
  • providing new pathways to widen participation. (Department of Health, 2000a)

Figure II: A workforce for culturally appropriate collaboration

Figure II: A workforce for culturally appropriate collaboration

 

 

 

Central to the provision of culturally appropriate care is valuing and working with the existing social units - including families, social networks, self-help groups, neighbourhoods - through which individual's day-to-day needs are met. There are wide-ranging health coalitions, which have historically functioned, in the minority ethnic communities, and mobilisation around common interests has led to major victories (Braithwaite, Taylor & Austin 2000). For example, the Health Equality Action Team (HEAT) in Bradford has made major advances in ensuring equality is a central focus of health policies in its' local region. Some of these support systems have resulted from resentment at the quality of services received by members of minority ethnic communities within the sector. For example the provision of mental health services for Black and Asian communities have been deemed to be ethnically insensitive and culturally inappropriate (Woodley Team Support 1995, Baylies et al 1993, Sashidharan and Francis 1993, Beliapa 1991).

Flexibility, adaptability and ability of the mainstream health service purchasers to learn from the experiences of the voluntary sector and coalitions in minority ethnic communities, are now integral elements of addressing the Government modernisation agenda (Archibong 2002). In addition the health service need actively to participate in the creation and sustainability of an extensive minority ethnic community independent sector, which works locally and directly with communities to make Our Healthier Nation a reality (Department of Health, 1998c).

The organisational role in making the NHS a better place to work has received great emphasis in the last few years (Department of Health, 1999c). One of the key challenges of a culturally competent organisation is formalising the context, structures and procedures, which promotes the building of knowledge. If utilised appropriately 'organisational knowledge assists in building new competencies and leveraging existing ones' (Stenhouse and Pemberton 1999). Such knowledge results from both personal and organisational learning and experiences. Each is dependent on the other and linked by organisational context.

The role of individuals in making the NHS culture ripe for diverse employees cannot be overemphasised. (See Against the Odds, Nurse Leadership programme, 2002). Staff development programmes on "valuing and managing diversity", as an essential programme for all staff, can foster appropriate cross-cultural working. Such training programmes could offer participants an opportunity to clarify their personal values, culture and beliefs and would serve to encourage participants to learn about and respect diverse perspectives of others in relation to aspects of their work. The programme needs to develop awareness of personal attitudes, sensitivity to issues of culture and ethnicity and learning skills necessary to negotiate cross-cultural communication and collaboration. This kind of programme is also useful at a basic professional health and social care education level with increased opportunities for multidisciplinary, team-based learning across health and social care, and scope for shared learning should continue to be explored and promoted. These opportunities for multidisciplinary learning are echoed in the Social Services Training Support Programme which emphasises the need for multidisciplinary and inter-agency training for health and social care groups to foster a common appreciation of respective roles and better working relationships in the interests of service users (Department of Health, 1999b).

Cultural proficiency

Multidisciplinary and inter-agency partnership requires individuals and organisations to work toward cultural proficiency. Cultural proficiency involves balancing respect for cultural beliefs and practices while maintaining professional standards of care. A further requirement of cultural proficiency is an organisational workforce with expertise in cultural and linguistic competence in health care practice and representative of the population it serves. It entails developing the ability to communicate in ways that transcend language as illustrated in the following example by Callister (2001). This illustration demonstrates how the midwife cared enough, from the heart, to make a difference to the quality of the birth experience of this family.

Example of cultural and linguistic competence

A midwife was assigned to a Chinese woman who spoke no English. The client's husband spoke little English, and from his perspective birthing was a woman's work. When the midwife came on her shift, the fearful woman was experiencing the intensity of transition. The Physician was present, frustrated by an inability to communicate with the couple, and the midwife could feel the tension that filled the room. The midwife could not speak Chinese either, but she tried to convey a sense of caring, touching the woman, speaking softly, modeling supportive behaviour for her husband, and helping her to relax as much as possible. The atmosphere in the room changed considerably with the calm competence and quiet demeanour of the midwife. Following the birth of a handsome son, the father thanked the midwife and conveyed to her how grateful he was that she spoke Chinese. The midwife tactfully said, "Thank you, but I don't speak Chinese." He looked at her in amazement and said with conviction, "You spoke Chinese to her."

Written agreements

The written agreement is a method of managing partnership described by Braye and Preston-Shoot (1992). The method has some legislative backing and has been written into documents such as The Children Act (1989); National Standards for the supervision of Offenders in the community (2002). One of the critiques of the written agreement is that it has the potential of disempowerment, and might serve to reduce the power balance in the professional/client relationship. Written agreements may be used to control the power base of the worker to the detriment of the power of the user. The best partnerships could be facilitated within a written agreement to minimise power differences. According to MacDonald (1991) this can be achieved if the parties can:

  • share a common understanding of the problems
  • have a degree of mutual trust
  • have a common way of expressing themselves
  • have a shared understanding of time
  • have a broadly similar view of the context in which the problems have arisen

Advocacy

Advocacy is another method of working, which promotes partnership. Advocates represent users, where they are unable to represent themselves adequately. They need to adapt the process to suit the needs and wishes of the people they represent. The user needs to feel in control of the process and should trust the advocate only to take action, which has been agreed. Advocacy is concerned with empowerment, and the support that is given to people to present their views for themselves. It ensures that people are able to make informed and free choices. Advocacy involves advising, assisting and supporting. Advocates should not pressurise or persuade, but empower the people they represent. The advocate needs to work with others to function properly and must not feel that he/she has to be self-sufficient. This role demands a complex set of skills and challenges the traditional notions of the relationship between carer, users and professionals. This can prompt a range of responses from antagonism to wholehearted support. There is a view that professionals such as social workers, carers, or general practitioners, can be advocates. It is important to note that these professionals may use advocacy skills and in some instances may advocate on behalf of someone. But the process needs to be guided by the user's agenda. Advocates must only promote the views of the user, irrespective of their advantaged position.

Equally there are constraints, which may result when carers act as advocates. Carers are constrained by their own obligations and duties and may find it difficult to represent people whose needs conflict with their own. Taking on the role of advocate can be distressing for all parties - professionals, carers and users. This distress in the advocacy process has led to the emergence of user movements, which posses the following characteristics:

  1. Members are assumed to be incapable of self-organisation because of incapacity thought to be an essential feature of their condition.
  2. They identify themselves in opposition to voluntary agencies organised for disabled people or other groups as groups largely composed of and certainly controlled by such people.
  3. They place emphasis on collective action as a means and an end
  4. Their underlying objectives are:
    a. To campaign for the inclusion of people previously excluded from mainstream society
    b. To influence the nature and pattern of services they receive
    c. To provide support for their members
    d. To act as advocates (both self and citizen advocates)

These advocacy groups seek to change the relationships between service users and those with direct responsibility for their care treatment. These groups operate in different ways. Some seek to disempower professionals whose interventions have been experienced as oppressive. Others work with sympathetic professionals or become involved in decision-making structures with professionals and managers who are not regarded as sympathetic, but whom the users are seeking to influence (Barnes, Harrison, Mort, Shardlow, and Wistow 1996). And there are other groups, which largely accept the medical model and the authority of professionals, but insist that service users should be able to express their views.

Examples of advocacy groups include the UK Advocacy Network (UKAN); the National Black Mental Health Association (NBMHA); People First - Self-Advocacy for people with learning difficulties; British Council of Organisations of Disabled People (BCODP); South Asians Elders Network (SAEN).

You will find it very helpful to look at the section on 'Advocacy' in the module Ethnicity and Learning Disabilities by Ghazala Mir.

Exercise 2.3 Group activity

Find out what Advocacy Groups are available in your local area.

  • do these groups reflect the different minority ethnic groups in your local area?
  • are translation services available?

    Compare your findings with other members of your group.

Charters

The use of charters is another way of managing partnerships. Charters are derived from the clearly identified needs of users, which have to be respected by the practitioners. Charters drawn up by users reflect their concerns, needs and demands (Bornat et al 1993) and can be empowering for the users. There is a need to understand that not all charters indicate true partnership within an empowering relationship. Cooper (1993) analysed the Citizen's Charter and confirmed that some charters represent a political attempt to 'depoliticise' social policy rather than being an instrument to empower citizens.

Dalrymple and Burke (1995: 71) criticise the patient's charter for assuming that "parents desire the same standards and objectives in education…there is no commitment to teach all children about other cultures, or to provide an anti-discriminatory curriculum". Cooper (1993: 157) describes some charters as being no more than 'an autocratic instrument attempting to impose standards, and to regulate social relations within civil society's domain.' This implies that public service charters can be disempowering and not necessarily in the best interests of the users. These should not be confused with the user-led charters, which can provide the basis of a partnership approach.

Service planning

It is common sense to expect that those who need services should have a say in those services - in determining what services they need, how the services are delivered and by whom. Problems continue to exist as both statutory and voluntary agencies see themselves, somehow, as those with the responsibility for protecting vulnerable people, despite legislative requirement for empowerment and participation and the genuine commitment to involving service users.

Harding (1993) offers the reasons for haphazard user involvement in care, in Building Bridges - workshops involving users and providers. These include a history of distrust and unequal power relationships between users of services and those who provide them. To have a successful partnership, users need to be able to build self-confidence, solidarity and strength through working together in groups. Bryan (1990) argues that empowering users means allowing them true participation, by regarding them as colleagues in the participative process and providers reaching out to them. MacDonald (1991) sees the involvement of users in the planning and management of care as one of the 'pillars' of community care and primary health strategies. Wallcraft (1990) suggests that before workers reach out to involve users, they need to ask four key questions:

  • why involve users? -The worker needs to consider the strengths and weaknesses of involving those who have previously been disempowered.
  • who do you want to involve? - The worker must check that the group does not become another elite one which is formed from hand picking those who will make positive contribution
  • who are you not reaching? - Women may not use the service unless there is a women-only space and provision for their children. Black people may find the service inappropriate and unwelcoming. Access may not be possible for people with disabilities.
  • what are you offering? - True user involvement is about honest assessment of the extent of user involvement. Clarify if it is consultation or direct contribution to decision making.

Formal structures of meetings, use of language and pre-set objectives may exclude people (Harding 1993) and may leave them feeling like outsiders with no notion of how to get their ideas heard or how to get involved in committee elections. Surrendering power and control can be quite difficult and threatening to some organisations, particularly if it involves surrendering control over resources.

The idea of getting a user perspective in influencing those who hold power has led to the development of campaigning organisations or user movements, which has already been discussed in the earlier section. A more specific example of these organisations detailing their role in users involvement in service planning is given in the box below.

Example of a specific service

Awaaz (Asian word meaning 'inner voice') is based in Manchester and has developed in response to the lack of services for members of the Asian community who have had negative experiences of psychiatric services. It acts as a resource by providing information and advice on a range of mental health issues. It works on the premise that if it can raise awareness about black mental health issues and change attitudes then this will eventually affect delivery of services. Services within the project are based on needs and experiences, as relayed by the users. One of the achievements of the project has been to support a Black Users' group in the local day hospital, where hospital staff are invited every three weeks to hear and respond to suggestions and grievances. Awaaz is also developing advocacy projects. Through these projects the gaps and inequalities in the provision of services for Asian people are highlighted.

One of the major challenges of organisations like Awaaz is the funding and resources needed to function effectively. Both central and local government have a major role in supporting and working in partnership with such groups to respond to the needs and experiences of service users in the planning and provision of services. Morris (1993a) asserts that putting resources into such organisations, and enabling the voice of users to be heard at all stages of community care implementation, should help to bring about the shift needed from service-led (Figure 1) to needs-led approach (figure 2).

Figure III services-led approach (adapted from Department of Health, 1998d)

Figure III services-led approach (adapted from Department of Health, 1998d)

 

 

 

 

 

 

 

 

 

 

 

Figure IV Need-led approach (adapted from Department of Health, 1998d)

Figure IV Need-led approach (adapted from Department of Health, 1998d)

 

 

 

 

 

 

 

 

 

 

 

The style of working needs to be determined for effective partnership in service planning with members of minority ethnic groups. There are different styles of working but the one appropriate for the Black and Minority ethnic communities is that which involves application of a set of different cultural values to the process of service planning and intervention. A culturally appropriate style of working acknowledges that service planning and provision must not be based on white, Eurocentric value systems. Professionals will bring a set of personal values and cultural assumptions to the process of care creating a cultural context for their practice. However the cultural context of the service user must be paramount in partnering with service users, and practitioners must always take direction from service users.

There is need for a paradigm shift, as many professionals will have to re-evaluate their Eurocentric and paternalistic approaches to accommodate a more equal power relationship with Black and Minority ethnic service users with a view to promoting a mutually desirable partnership. The general and the specific duties of the Race Relations (Amendment) Act (2000) provide the basis for a consistent approach to services generated by needs of the service users. The Act emphasises the need for assessment and consultation on proposed policies and services with a view to revising provisions based on the users' views and experiences.

Users involvement in partnership and service planning should also mean involving users in the recruitment and selection of staff. This process is increasingly taking place in the voluntary sector but less so in the statutory sector. To participate effectively in the process, users need appropriate training so they are properly prepared for what can be an intimidating task. There is also a need to train professionals in genuine user participation.

Exercise 2.4 Self reflection activity

Partnerships need to be worked at. Think of a situation where:

a) a partnership would be ideal;
b) a partnership would be impossible
c) a partnership is ideal

This could be either in your work situation or within your personal experience. Write down your feelings about each of these situations. In particular think about the following areas:

  • what would make you feel good and positive about partnership?
  • what makes you feel uncomfortable and why?
  • what would make you feel undermined or threatened by the partnership?

Promoting culturally sensitive user involvement in health and social care research

Recent interests in evidence-based practice have had remarkable change on professional practice and have impacted on the volume of research activity across health professional groups (Roe and Webb 1998). While evidence exist to show that the involvement of users in research changes the priorities for research, little effort has been made by some researchers to involve black and minority ethnic users in their work (NHS Executive 1999). There is a strong history of mistrust of research within diverse communities, particularly 'communities of color' and among other non-ethnic cultural groups. It is a well-documented fact that communities of disenfranchised persons tend to distrust researchers and other professionals (Sieber, 1992). Such beliefs and perceptions have their roots in historical, and unfortunately current experiences that members of culturally and ethnically diverse groups have encountered in this nation's health and social care delivery systems. Many of these individuals typically view research through a prism of victimisation and fear. This mistrust is reinforced by widely publicised research, such as the Tuskegee study, which continues to have ramifications on how medical and health care research is viewed among segments of the African American population today (Stevens, 1995).

Exercise 2.5 Self reflection activity

Consumers in research, a sub group of the NHS Central Research and Development (R & D) Committee, was set up in 1996 (Department of Health, 2000d). It aims to ensure that consumer involvement in NHS R & D improves the quality of research.

  • identify the strategic objectives of the Consumers in Research.
  • consider how well these objectives can be developed users from different cultures.

Visit the following website to access this information: www.conres.co.uk

Research will likely have greater validity and relevance for the groups studied if the projects or proposals are culturally based and reflect the cultural competence of the practitioner, researcher or research team (Brandt, et al., 1999). Research will also prove more valuable if groups who are studied have an investment and are active participants in all aspects and phases of the research process. Culturally competent research is characterised by the inclusion of participatory action or advocacy-oriented methodologies. This type of research strengthens the effectiveness of professionals, organisations, and service systems by providing them with accurate information to improve the efficacy of their work, and empowers diverse communities by equipping them with the knowledge and skills to understand health care issues and intervene on their own behalf. Such participatory action research is also a powerful approach for achieving cultural competence in research methodologies.

Infusing participatory action models into culturally competent research generates knowledge in ways that promote partnerships between disparate stakeholders, builds capacity within communities, and ultimately strengthens community-based and other organisations working to improve health conditions in diverse communities. Participatory action research allows researchers to learn about the strengths, needs and circumstances impacting on those they seek to assist, and offers opportunities for the community to learn about the uses, requirements, limitations and benefits of research. When program participants are involved in the generation and use of knowledge, it enables different groups of people to act collectively based on informed decisions. A major benefit of this research model is a coalition of stakeholders informed and prepared to effect and sustain change in an effort to improve health care. Culturally competent research should also incorporate the value of reciprocity, which is demonstrated by benefits derived from the allocation of fiscal and other resources to individuals and diverse communities that are studied.

Memo

  • partnership is not based on equal power relationships between partners.
  • effective collaboration is enhanced by the promotion of a diverse health and social care workforce and the development of a culturally proficient workforce.
  • partnership between users and professionals can be effectively managed by the use of written agreements and appropriate advocacy arrangements.
  • charters drawn up by users can promote effective partnership and can be empowering for the users.
  • users involvement in service planning and implementation can promote shared ownership and understanding of different cultural values within the process of care.
  • cultural knowledge must inform the entire collaborative research process.

Empowerment

One of the challenges of a successful partnership working, as already described, is the unequal balances of power within and between partnering relationships. Empowerment is about understanding and trying to balance these power relationships. There has been increasing use of the term empowerment between the late 1980's (Adams 1990) and the 1990's, where it is used to reflect the nature of social and health care or to describe a move towards greater equality of partners involved in community care activities (Stevenson and Parsloe 1993).

The notion of empowerment has formed the basis of the recent government framework for care. For example it is central to the Managers and Practitioners Guide to Management and Assessment, which maintains that the rationale for this reorganisation is the empowerment of users and carers (Department of Health, 1991b).

Exercise 2.6 Self reflection activity

  • what does the term empowerment mean to you? You may find it helpful to jot down a few ideas that come to mind
  • can you think of a time when you have felt empowered? Describe the situation. Who was involved? How did you feel and how did you respond?

There is a variation in how people experience being empowered and this leads to an understanding of what empowerment means to us individually. Some ideas that may emerge about empowerment, as identified by Kirton and Virdee (1992) and Dalrymple and Burke (1995), include:

  • Gaining more control over your own life
  • Being aware of, and using, your personal resources
  • Overcoming obstacles to meeting your needs and aspirations
  • Having your voice heard in decision making
  • Being able to challenge inequality and oppression in your life

According to Dalrymple and Burke (1995) empowerment is about not making assumptions, but asking the question why. "Critical analysis is the forerunner of empowerment." Solomon (1976: 12) defines empowerment as " a process whereby persons who belong to a stigmatised social category throughout their lives can be assisted to develop skills in the experience of interpersonal influence and the performance of valued social roles." Solomon's work looks at the negative valuations that people in black communities have been subjected to. This work is equally relevant to other minority groups who are negatively valued within society. Solomon maintains that empowerment involves the engagement of service users in the problem solving process. This process can serve to offset the discrimination that faces those who have little or no access to the power and decision making structures. One way of promoting service users' involvement in problem solving is by enabling them to talk about their experiences of discrimination. The work of black female writers (Hooks 1989, Hill-Collins 1990) in the documentation of the experiences of black women through the sharing of their personal experiences of discrimination can help women to take over control of their lives and begin to value themselves. Once people are empowered they begin the process of rejecting the system which once discriminated against them. It is incumbent on the health and social care professionals to promote structures and processes of service delivery that have the greatest potential for facilitating empowerment of service users and their families. Practitioners must provide services that are sensitive to the needs of service users through listening to, and taking accounts of, people's experiences. As Solomon (1976: 29) points out "the success or failure of empowerment is directly related to the degree to which (the) service delivery system itself is an obstacle course or an opportunity system."

The Process of empowerment

This is a process of change, which is described by Rappaport (1984) as multifaceted and multidimensional. The process involves making the links between our personal position and structural inequalities. Empowerment at a micro level is concerned with the development of a personal feeling of increased power or control without an actual change in structural arrangements. On a macro level it is a process of increasing power. Another level of empowerment is the interface between the micro and the macro levels, whereby individual empowerment can add to group empowerment. In turn, the increase in group empowerment can augment the role of its members. There are many models to illustrate the empowerment process (Rappaport 1984, Fierre 1972, Rose and Black 1985, Rosenfield 1989, Thompson 1993, Hasenfield 1987, Troyna and Hatcher 1992, Dalrymple and Burke 1995). There are 3 stages, or levels, of the process - level of feeling, level of ideas and level of action.

Figure V: Levels of empowerment

Figure V: Levels of empowerment

 

 

 

 

 

 

Level of feeling:

This is about the personal experiences of the individual who is feeling powerless. This level equates with Hill-Collins' (1990) level of self-conscious struggle. Troyna and Hatcher (1992) identify 3 stages of the level of feeling as interactional - about the actual incident; contextual - to do with the immediate history of the incident; biographical - concerns the factors and characteristics specific to the individuals involved in the incident.

Level of ideas:

Rappaport (1985) refers to this as the level of self-worth. This level involves increasing self-efficacy or a belief in the ability to 'produce and regulate events in one's life ' (Bandura 1982: 122). At this level people begin to develop their sense of personal power or strength and a sense of control. This is the period of developing client initiative or increasing the users' ability to act. Troyna and Hatcher (1992) outline three stages within the level of idea in their work with young people in school - subcultural, institutional and the cultural. They view the institutional stage as 'ideologies, procedural norms and practices, which are promoted, sanctioned and diffused by school.' At cultural level, they refer to young people experiences in terms their 'lived experiences and common-sense understanding.' Developing personal power and indeed, self-knowledge, enables people to develop new language that expresses power.

Level of action:

This level involves the movement from the personal to the political. Hasenfield (1987 cited in Holdsworth 1991) views this as ensuring that formulation of policy decisions is influenced by those who are directly affected by them. For a successful empowerment practice, there is need for organisational change through the development of raised consciousness and the subsequent awareness of the possibility of political and social action. The process of political action concerns the ability to work with others to change social institutions, assisted through the development of an awareness of how political structures affect both individual and group experiences (Gutierrez 1990). This level is accompanied by the real danger of people doubting the action they have been taking. It is at this level that people will need the appropriate support to stay focused on the action they are taking or they may return to the former stage of powerlessness. The purpose of empowerment at this level may be to change legislation or policies, or it can be about the small changes that may affect the life of one individual, which in Rappaport's (1985) terms is about making a difference in the world around us.

In summary, the model describes empowerment as occurring on individual, personal and institutional levels. The individual being able to describe their feelings, develop a sense of personal power, affect others and work with others to change social institutions.

Exercise 2.7 Self reflection activity

Think back to your early study of the concept of communities of practice. Reflect on how the dynamics spelt out in that discussion would help you to understand better how these three levels of empowerment would have to be negotiated in your place of work.

Principles and assumptions of empowerment

DuBois and Krogsrud Miley (1992) compiled some guiding principles described by various authors (Solomon 1976, Rappaport 1984; Pinder-Hughes 1983, Swift 1984, Swift and Levin 1987), which should underpin our practice if it is to be truly empowering for service users.

  • empowerment is a collaborative process, with the client and the practitioner working together as partners
  • the empowering process views the client systems as competent and capable, given access to resources and opportunities
  • it is important that clients first perceive themselves as causal agents, able to effect change.
  • competence is acquired or refined through life experiences, particularly experience affirming efficacy, rather than from circumstances where one is told what to do
  • solutions, evolving from the particular situation, are necessarily diverse and emphasise 'complexities of multiple contributory factors in any problem situation' (Solomon 1976)
  • informal social networks are a significant source of support for mediating stress and increasing one's competence and sense of control
  • people need to participate in their own empowerment; goals, means and outcomes must be self-defined
  • level of awareness is a key issue in empowerment; 'knowledge mobilises action for change' (Swift and Levin 1987)
  • the empowering process is dynamic, synergistic, ever changing and evolutionary; problems always have multiple solutions
  • empowerment is achieved through the parallel structures of personal and socioeconomic development.

Exercise 2.8 Self reflection activity

Maniz is 15 years old. She has a younger brother, Isa, who is nine years old, and a sister Talib, who is four years old. Maniz' mother, Robeena, is a single parent. Maniz' dad died three years ago. During the past six months, according to Robeena, relations between herself and her daughter have deteriorated and they have been arguing on a daily basis. Maniz has, during this period, been seen by a number of people in the community with a young man who is said to be in his twenties.

Recently, Maniz has been staying out late - this fact has infuriated Robeena, who is concerned about her moral welfare. Robeena has accused her daughter of being lazy and selfish. Maniz in turn believes that her mother excludes her and has more time for her younger siblings. Maniz has at times, after a row with her mother, gone to live with her maternal grandmother, who lives some distance away from the family home. While there, Maniz does not attend school on a regular basis.

You are a worker involved with the family to try and improve the situation for Maniz and ensure her regular attendance at school. Draw up a partnership agreement on the basis of the information with which you have been provided. In devising the agreement:

  • consider issues of ethnicity, culture, religion and language
  • how everyone in the scenario might be consulted
  • if there is anyone to be left out, or you do not feel is appropriate to be involved, please give your reasons for this.

How do you attempt to sustain and promote contact between Maniz, her family, friends and the community?
How would a partnership agreement empower the people in this scenario?
There is a potential for working agreements to disempower service users. What are the elements in this case that could be misused?
What do you think are the key issues if service users are to be involved in meetings?

Memo

  • empowerment is about being able to hold on to and defend one's values, and have some critical awareness of the interaction that takes place between individuals.
  • empowerment process involves making the links between personal position and structural inequalities

Conclusion

This module has provided a wide-ranging introduction to issues of multi-disciplinary and multi-agency partnerships in developing culturally safe practice. It has emphasised that such styles of working are now very central to current health care policy and practice. The principles, which should inform the development and practice of partnerships, have been discussed in some detail. However, professional training is still relatively compartmentalised and professional identities are powerfully policed in many communities of practice. Thus resistance to developing any effective inter-professional partnerships is easily found. Where there is a partnership, which also involves a key commitment to mutually developing culturally safe practice, resistance and unintended misunderstanding can be more deeply entrenched. Different professional and institutional understandings of how to address diversity are not always made explicit. The hidden informal leadership networks that make agencies work may not adequately map the formal structures, and 'official' inter-agency dialogues that often are central to the early stages of building partnerships.

Additionally majority ethnic professionals may legitimately feel enthusiastic and committed to developing partnerships with voluntary sector organisations and be stung by their caution or abrasive style. Those who possess the dominant position in terms of resources and 'official' power must be sensitive to the possible prior experience of voluntary sector agencies and workers. They may have a cumulatively negative experience of being "switched on and off" at the whim of Government and local government initiatives.

The extensive experience of the Black and Minority ethnic voluntary sector in defining client needs, and in developing appropriate health care responses is a major resource to the current emphasis on inter-agency working. As the module on Ethnicity and Learning Difficulties explored, there are important questions to be asked about whether such collaborative work should have a generic, or ethnically specific, client focus. Certainly it is essential that there should be a highly developed capacity for collaboration between generic services and ethnically specific service providers in order to optimise their combined benefits to health and social care users.

Throughout the spectrum of health and social care provision inter-disciplinary and multi-agency working provides a framework for shared learning and a meshing of experience and competence in delivering culturally safe practice.