More Than Just A Spanner In The Works

More Than Just A Spanner In The Works

in General November 13, 2014

Independent advocates in Scotland work across many different boundaries in supporting people to speak up about what is important to them. They do this without the need for formal qualifications and without external scrutiny of their practice. It is not uncommon for them to be regarded by the professionals they come into contact with as untrained and lacking in knowledge – a situation referred to by some researchers as a ‘troubled one’. Yet such a role is not without its own unique set of competencies, which are being increasingly recognised in a growing body of literature, which refers to them as ‘boundary spanning’. This article establishes the role of the independent advocate as a boundary spanning one, and having done so proposes a three aspect approach to recruitment, training and support for people carrying out the role. All names have been changed, and situations adapted to protect anonymity.  

Accessible Summary

  • Independent advocates in Scotland work in many different settings on behalf of the people they advocate for. This can be called a boundary spanning role
  • At present, they have no need to have a specialist qualification to do this
  • This article looks at how they could be better prepared for their role if they could access training and support which recognised the boundary spanning aspects of their work
  • This would reassure people using advocacy that the advocates were providing a good service

An Introduction To Independent Advocacy

Carol’s working day starts with a visit to a local nursing home to meet Tom, who has dementia. She knows that Tom’s daughter is applying to the court to take guardianship over his financial affairs. She has been visiting Tom for a few weeks to try to ascertain his views on this as she will be repeating these in court on his behalf when the application goes before the sheriff.

Her next appointment is to accompany a parent (Marion) to a children’s hearing which has been convened to make a decision regarding the removal of Marion’s children from her care on a long term basis. Marion feels this is unfair and wants Carol to help her put over her point of view. When the hearing decides that the children would not be returning to Marion’s care, she becomes upset, and it is Carol who ensures that Marion is supported to ask for letters and photos to be sent to and received from her children.

Carol’s third visit of the day is with Sheila, who is detained under mental health legislation in a hospital on the other side of the country from where she usually lives. Sheila’s case is to be discussed at a mental health tribunal within the next few days. Carol is helping her find a local solicitor to provide legal representation, and to liaise with her family and supporters from her home area.

The above examples are not fictitious case studies, but an extract from Carol’s diary. The only change has been to the names. She is not a social worker or healthcare professional as may be assumed from the context, but a worker from a local independent advocacy organisation. It also may be assumed that she requires some formal qualification or professional accreditation of her practice. However, within Scotland, no such regulation exists, other than that put in place by individual organisations, or by voluntary adherence to a suite of guidance documents compiled by the Scottish Independent Advocacy Alliance(SIAA), the national membership organisation for independent advocacy services in Scotland

Background

The position of independent advocates has been described as a troubled one(Forbat & Atkinson, 2005) with recognition that advocates work in what is often felt to be a hostile environment.
“They are, after all, outside and independent of mainstream health and social care systems, having to challenge professionals and speak up for those who are oppressed or disempowered, often through or because of those same organisational systems.” (Forbat & Atkinson, 2005,p333)

One particularly vehement example of hostility is to be found in Frank Corrigan’s correspondence to The Psychiatrist (2008) where he writes of advocates “ peddling of an anti-psychiatry agenda independent of the wishes of the patient”, who “pursue a mission to find fault with services regardless of the welfare of the patients” and times where the advocate’s “presence moves from being unhelpful and time-consuming to being dangerous”(p156).

The Mental Health (Care and Treatment)(Sc) Act 2003 was a pivotal piece of legislation for independent advocacy in Scotland. For the first time, statute accorded the right to access independent advocacy to anyone with a mental disorder. That is anyone with mental ill health, learning disability or personality disorder. NHS Boards and their local planning partners were also accorded the duty of ensuring that advocacy services in their area were available for those who gained this right of access. However, the availability of advocacy is very much area dependent, as is the nature of the agreements under which advocacy services are commissioned. The current situation, along with its “patchy nature” was acknowledged in a limited review of the legislation carried out in 2009 (Scottish Government 2009, Chapter 3), with illustration found in the Map of Independent Advocacy accessible on the SIAA’s website (www.siaa.org.uk).

Concerns about the effect of so much statutory involvement were voiced by Jackson who, writing in 2002, posed the question “Does advocacy have a future?”, centring his argument around what he considered a four stage lifespan for advocacy services which are supported by the public purse. He saw these as evolving from initial enthusiasm, through being seen as a potential threat when people were supported to challenge, into a phase of containment when advocacy services are reined in. It could be argued that this third stage can be seen in the shifting status of independent advocacy in Scottish legislation, being diluted from a statutory right in the 2003 Act to a ‘consideration’ in Adult Support and Protection (Sc) Act 2007. Jackson goes on to describe a final stage, where advocacy becomes limited by the restrictions of a contract, or becomes absorbed into statutory structures. Some evidence of this can be seen in Scotland at the time of writing, with competitive tendering being used as the commissioning vehicle of choice in a growing number of areas, even though it is seen by the Scottish Government as “not a creative way to achieve the effective provision of advocacy” ( Jackson 2002, p23). Equally, the final phase may come from the actions of the advocacy organisation itself, who, by not accepting the restrictions asked of them, find themselves un-contracted and having to close down.

The impact of the growth of public involvement in the commissioning of independent advocacy services is also considered by SIAA in a recent paper, Ten Years of Advocacy Provision (SIAA, 2013),which looks in detail at the range of advocacy provision available in Scotland over the last decade. The findings seem to back up Jackson’s concerns, showing a reduction in the number of advocacy services available now, when compared with ten years ago as organisations have either merged or been absorbed by others.

Working within an independent advocacy organisation, I have a personal perspective on the points Jackson makes and can see parallels in the four stages he describes within our own organisation as well as nationally. If we are to avoid entering the final stage, I consider that action needs to be taken now to retain the unique and valuable service we provide to some of the most marginalised people within our communities. This, I feel, requires us to have a critical look at the current situation and consider whether change is required. Such reflection, I would contend, is valuable both within the individual organisation as well as on a wider scale.

Avoiding Jackson’s fourth stage will, I consider, require more than yet another guidance document from the SIAA on an ever more specialised area of advocacy. Here I agree with Stewart and MacIntyre (2013) who consider “conflicting definitions and a lack of understanding about the role of advocacy” are impeding any clear evidence of its impact. Instead, I suggest we need to look in another direction, and recognise the unique underpinning features of independent advocacy and the range of competencies required to carry it out. Rather than avoiding the need for external scrutiny of advocates’ practice as happens now, I consider that there is a need for formal recognition of what the role of an independent advocate entails, and accreditation of the competencies required to carry it out, along with confidence that independent advocacy can be seen as a discipline in its own right. The need for practitioners to understand their role and be confident in their practice is also reinforced by Stewart and MacIntyre.

In this I diverge from Jackson(2002), who considers that “training may impart knowledge of a highly prescriptive nature which can discourage advocates from exercising common sense, initiative and flexibility, the essential qualities sought in the ideal advocate” (p26). I suggest, instead, that it is possible to implement a framework of competencies in a manner that reflects the underpinning foundations and would enhance rather than detract from its essential nature. Independent advocates would then be given recognition for the rigour required to carry out the role, rather than as Corrigan (2008) sees them as “unskilled, untrained staff with a remit to undermine“. Putting forward this suggestion, I acknowledge that it diverges, too, from the thinking of Stewart and MacIntyre (2013) in their suggestion that advocates require specialist training to work in specific contexts.

In consideration of what such an overarching framework would look like, I have considered in this paper existing relevant literature, both within the context of advocacy itself, and from related disciplines, before suggesting a way forward.

Guidance for independent advocates in Scotland

Independent advocates in Scotland lack national regulation of their role or the skills, experience and knowledge required to carry it out. This is unlike their counterparts in England and Wales, who have an established framework of competencies and qualifications to accredit their practice (www.cityandguilds.com) The guidance documents which do exist are, in the main, published by the Scottish Independent Advocacy Alliance (SIAA 2008-2013) and are dependent on the voluntary implementation by the organisations providing advocacy and their internal monitoring systems. Increasingly, these have been set within a particular context, such as mental health tribunals (SIAA 2012) or related to a specific client group, such as people who have experienced a stroke (SIAA 2009). This seems to contradict the intention of the first of these documents, which sets out a set of Principles and Standards (SIAA 2008) purporting to apply to all advocacy models and contexts. In considering the examples given at the beginning of this paper, it can be seen that an individual advocate may have cause to consider more than one set of such detailed guidance for the person they are advocating for.

I contend that this needs to be acknowledged, and, rather than contextualising the work into specific themes or with specific client groups there is a need to recognise the importance of, and difficulties inherent in, the cross cutting nature of the contexts in which independent advocates work and to ensure people carrying it out are properly prepared for and supported in this role.

Independent advocates as boundary spanners

Within public service organisations there is a growing body of evidence of the need for roles which span boundaries. This is becoming more relevant in the realms of social care and health as the government’s strategy for these services to be integrated moves forward. The recognition is also growing of the need for such roles to be at all levels of the organisation from front line staff to strategic management. It seems timely, therefore to consider how the role of an independent advocate corresponds with the essential features of the ‘boundary spanner’ as opposed to the “spanner in the works” as they are sometimes seen by the professionals involved in a person’s life.

Williams (2012) considers that the issues that form the mainstay of a boundary spanner’s role can be complex and interconnected and “cut across the conventional boundaries of organisation, profession, sector, levels of governance, geographical area, time and policy” (p27). He goes on to identify four aspects of the boundary spanners role:

Reticulist – requiring understanding of relationships, communications and how these can best be managed. We can see this aspect in Carol’s activities in building links with Sheila’s support team at home and in hospital, with her family and linking her with services local to the hospital, such as a solicitor.

Entrepreneurial – developing new solutions or bringing new ideas to the decision making process such as in Marion’s case from the beginning of this paper.

Interpreting/communicating – appreciating the need to respect individual and organisations cultures and being able to communicate with a wide range of people, seen in all of the examples above.

Co-ordinating – bringing together differing groups of people and ensuring everyone does what they say they will – an everyday task for the independent advocate.

As can be seen here, we can find all four aspects of the boundary spanning role in Carol’s work. In the three cases cited, we can also see that she crosses boundaries of organisation, status, geography and interest, all adding to reinforcement of the independent advocate as a role of this type.

I will now look at the effect on the advocate of carrying out such a role.

The cost of advocating

The day to day work of independent advocates in Scotland is guided by four principles, the first of which states:
“Independent advocacy is directed by the needs, interests, views and wishes of the people who use it.”, and, that independent advocates “represent the wishes and views of their partner, not their own interests or those of others.” (SIAA 2008,p14)

Thus the independent advocate’s working life often involves representing interests and views which may differ from their own and where the competing interests of other agencies in the room may be united against them, accurately depicting what Williams describes as a working life filled with “paradox, ambiguity and tension” (Williams, 2012 p 25).

The effects of working in such an environment were illustrated in a study conducted by myself and a colleague, set within our own organisations (McClurg & McGlone, 2007). Both organisations had recognised that workers were finding their work ever more stressful. A qualitative study was carried out to ascertain the costs involved in advocating and what could be done both by individuals and the organisations to alleviate the situation. Similar themes emerged in both organisations, with no advocate experiencing no cost to themselves as a result of their work. There was an overall agreement on the need for support which recognised the integral emotional and personal challenge of the advocates’ role as well as the ‘nuts and bolts’ of the issue they are working on at the time.

Similar findings resulted from the qualitative study carried out by Carver and Morrison (Carver & Morrison,2005), which looked at the experience of independent advocates providing advocacy for people in psychiatric hospitals in England. Here too, the additional stress of having to fight for recognition by clinicians and other ‘professionals’ in a person’s life was found to detract from the effectiveness of the advocacy provided.

“The Right to be Heard” (University of Central Lancashire, 2012) is a report of research carried out by the University of Central Lancashire to review Independent Mental Health Advocacy (IMHA) Services in England. The findings acknowledge the differing power dynamics at play within an advocacy relationship, including those between the advocate and the mental health services. In arguing that a shift in such relationships can bring a more positive outcome for the service user, the findings seem to emphasise the reticulist aspect of the boundary spanning role and the need to delicately balance the relationship between the advocate and service professionals. This balance is viewed as difficult to get right, as to be seen to have too positive a relationship may cause the service user to question the independence of the advocate, but on the other hand, where the relationship completely breaks down this can also inhibit the service user from engaging with advocacy services.

The delicate nature of the interface between the independent advocate and other services was explored also in the mixed methods study carried out by Forbat and Atkinson (2005) which looked at five organisations carrying out advocacy in Nottinghamshire. Along with findings related to the effectiveness of different models of advocacy, they identified “a downside to being an advocate, in particular the stresses of working in an isolated role, sometimes in a hostile environment.” (p329). They describe the tensions in the role of the advocate when challenging other service providers on behalf of their advocacy partner and where advocacy is included in the role of another agency.

All of these studies set within an advocacy context back up the findings of Ashill, Meadows and Stewart (2001) into the stressors that affect those in boundary spanning roles within public sector agencies. This study found that in addition to the stressors found in single role positions, boundary spanners face additional stressors attributed to the unique demands of the role and the uncertainty faced in their everyday work. They therefore required support and supervision strategies that took this into account.

I will now turn to look at what the literature shows that people were looking for to prepare them to undertake such a role and support them once they are carrying it out.

Supporting independent advocates as boundary spanners

“Here for Good?”(Action for Advocacy, 2008), gives a “snapshot of the advocacy workforce” in England and Wales in 2007. A recurrent theme in the responses from advocacy workers was the need to have good supervision and support in their role, both in terms of the work they were doing for their advocacy partners, but also emotional support for themselves.

“In advocacy, the isolated nature of work may well make it harder to deal with its emotional impact. …A failure to address the emotional needs of advocates could make it less likely for them to remain in the sector.” (p11)

In the study carried out by Forbat and Atkinson discussed above they conclude that “provision of support should be mindful of the troubled position that advocates hold.” (p333) and that the support provided to them should be both managerial and counselling in nature. It is also recognised that there are responsibilities inherent on other agencies to ensure that staff are clear about the independent advocates’ role.
This is reflected, too, in the conclusions reached by Carver and Morrison.

The need for general support in the role of the advocacy worker as well as specific training in particular aspects of it is found, too, in work done by Sense in 2010 ( Lee, 2010). “Capacity to Communicate” tried to ascertain the training needs of people acting as advocates for those who were born deafblind, and design a training package to fit. Again, a mixed methods approach was taken, with participants contacted on three occasions over a three year period.

Although the aim of the programme was to provide training in communication in regard to a specific client group, the responses to the first stage of the project yielded the outcome of a more general approach being preferable.

The training needs identified included :

  • develop more confidence in advocating for those who lack capacity or have no formal communication
  • gain a wider view of possible communication methods which could be utilised in different circumstances
  • raise awareness of different approaches to decision making and guidelines for using them
  • explore moral and ethical issues inherent in the advocates’ role

Responses to the second stage of the research also indicated that advocates had used the work covered in wider and differing contexts.

Building on their findings, the authors of this research concluded that there were three fundamental parts to the advocates’ role, regardless of the client group or context.

These are identified as the ability to be a:

  • Good communicator – able to adapt communication methods to the situation
  • Confident investigator – able to ask the right questions of the right people at the right time
  • Confident evaluator – with the ability to assess and analyse information from a range of sources, some of which may conflict with others

All of this, they conclude, requires “integrity, rigour and accountability” (p37) on behalf of the advocate. The toolkit that was constructed to fulfil the training needs identified accordingly took this wider view in its final published form.

A mixed methods study carried out by the University of Glamorgan (Llewellyn & Northway, 2007) set out to look at the view of learning disability nurses in Wales in regard to their advocacy education. A distinction was made by participants between “learning about advocacy” and “learning to advocate” (p961)
“ Several nurses commented that learning how to advocate is ‘much harder’ than simply learning the theory, and others pointed out that nurse advocates need to be aware that they might ‘open up a variety of issues, both ethical and professional’ when they attempt to put theory into practice. “(p961)

Not least of these would be the potential to challenge the views of their employer when representing the views of their patient. Like the views of the independent advocates summarised in the previous section, the training needs expressed here are in regard to the self reflection and intrinsic values of advocacy, rather that the knowledge and information required in individual advocacy situations.

Similar findings were expressed in the work by Foley, Minick and Lee (2002) in their research involving American military nurses. Once again there were overlying themes, similar to those identified above, that the nurses identified as key components of being a good advocate.

In this study these are defined as :

  • Who I am – it was recognised by respondents that advocating was part of their own character. If nurses were used to speaking up for others elsewhere in their lives, they did this in their nursing role as well.
  • Observing others – some nurses had begun advocating for patients as they had seen other nurses doing so. Their learning how, therefore, was through observation and asking reflective questions. This they had found invaluable.
  • Gaining confidence – this was felt to be acquired though having a supportive environment to advocating for patients and the freedom to do so even when the desired outcome may not have been achieved.

In the wider context of boundary spanning, the need to balance training, support and getting the right people for the job is also recognised as key for successful boundary spanning. Williams (2013) treats this as what he refers to as a “competency approach”, with competencies described as, “ a combination of both technical and human skills, knowledge of particular areas of expertise and accumulated experience.”(p20) In relation to the nature of people thought effective in this type of role, he adds, “ Actors also possess personal attributes that, although not competencies as such, influence the manner in which competencies are undertaken in practice.” (p20). The need to consider the personal qualities of a good advocate is also highlighted by Stewart and MacIntyre (2013)

who list the following attributes:

  • A calm thoughtful and sensitive disposition
  • The ability to raise relevant issues on behalf of the person in an appropriate and fair manner
  • Good at building relationships with people
  • Provision of support to individual when upset
  • Ensure the person’s views are discussed and incorporated
  • The ability to be succinct, articulate, thorough and offer alternative ways of thinking
  • Facilitate understanding among other professionals of the person’s situation ”
  • Stewart and MacIntyre (2013)

All of these can be seen to articulate with the four aspects of a boundary spanner’s role identified by Williams and discussed earlier.

How does the advocacy landscape in Scotland reflect the boundary spanning nature of the role
In accepting the role of the independent advocate in Scotland as a boundary spanning one, it seems reasonable, therefore, to accept established findings as to the support and training needs of people who fill that role. As seen above,

This appears to require three inter-related threads:

  • Getting the right people for the job
  • Ensuring they are doing the right things
  • Providing them with the right support.

As of now, the recruitment, support and supervision of independent advocates are the business of individual organisations. The suite of publications provided by the SIAA provides much support to them in regard to what both individual advocates and the organisations should be doing, both generally and in specific contexts. The increasing compartmentalisation of its publications seems to bear little relevance to a boundary spanning role, however, as little guidance is provided by the SIAA in regard to the underpinning philosophy of independent advocacy, or in terms of academic debate on its impact or effectiveness. Similarly, there is little information available from them on the content of any training, as this is left to the individual organisations or to the offerings of private training providers. This is in stark contrast to the recognised curricular framework available to those carrying out the role south of the border.

Next steps

As will be recognised by readers of this article, very little of the literature considered above comes from Scotland. A comprehensive search carried out by the writer yielded few research findings. Missing too, seems to be a central focus for academic discussion and debate on aspects relevant to independent advocacy. The list of references at the end of this paper illustrates a wide and varied range of sources, with no journal focusing on independent advocacy alone.

Most of the available literature comes in the form of guidance documents, collections of advocacy stories and case studies or perspectives on advocacy by individual writers such as Donnison (2009) or Gammack (2011). Organisations such as The Institute for Research and Innovation in Social Services (IRISS) have published documents such as that written by Stewart and MacIntyre (2013) attempting to bring some clarity about advocacy to other professions. However there is no clear forum to debate the issues raised or challenge any areas of disagreement.

None of the available Scottish literature has looked at the role of the advocate from a boundary spanning perspective and at the benefits to the recipients of advocacy services of receiving advocacy from a person who has had access to training and support designed to develop their competency in their role.

Within my own organisation, we have taken steps to remedy this. Alongside an integrated process of support and supervision, advocacy workers have been given access to the NVQ Level 3 training programme usually available only in England and Wales. The model of delivering the programme has taken account of the research done elsewhere of the training needs of advocacy workers and those in other boundary spanning organisations. The delivery model adopted has also been chosen to reflect these needs and uses a practical philosophical approach to the topics under consideration, backed up with an integrated process of support and supervision. Throughout the implementation of the programme, those involved have been actively involved in co-researching the effect on their practice, and the findings will form the basis of a later publication.

However, the actions of one organisation, or the writings of one individual will not be sufficient to give independent advocacy a positive future, to be seen as a discipline worthy of respect in its own right. This will require those involved in its provision to have the confidence to put forward their own ideas and engage in debate and dialogue around them, such as through the setting up of a community of practice. This can only aid improvements to practice and ultimately benefit the people we advocate for.