BLI: Being Least Intrusive - An Orientation to Practice for Front-Line Workers Responding to Abuse of Aboriginal Older Adults

Being Least Intrusive emerges from the front-line challenges of practice in responding to situations of abuse, neglect and self-neglect of vulnerable First Nation adults living in on-reserve First Nation communities. It is a hybrid approach, which draws on indigenous knowledge, key concepts from critical social work theory and first-hand accounts of response and prevention initiatives within First Nation communities across Canada. It has been developed to assist front-line service providers (primarily non-aboriginal) in orientating themselves to respond to situations of abuse, neglect and self-neglect of vulnerable First Nation / Aboriginal adults in a way that:

  • Is Culturally Safe;
  • Facilitates a holistic understanding of health and wellness;
  • Honours cultural and spiritual diversity;
  • Creates space for collaboration and partnership;
  • Acknowledges the strengths and resiliency of individuals, families and communities; and
  • Ensures safety, protects dignity and encourages empowerment.

Being Least Intrusive presents a fundamentally different approach to health care service delivery. It challenges front-line workers to:

  • Engage in critical practice;
  • Understand issues of vulnerability, abuse and neglect in the historical, social and cultural context in which they emerge and are experienced;
  • Develop a critical self-awareness (understanding how your social, cultural identity and experience shape knowledge, awareness and interactions);
  • Be thoughtful, intentional and respectful in engagement with individuals, families and communities.

Being Least Intrusive was developed within the socio-legal context of British Columbia’s provincial adult guardianship legislation. However, we believe that the concepts and principles underlying this approach to practice and process of engagement are applicable across jurisdictions and geographical regions.

FOUNDATIONAL PRINCIPLES AND CONCEPTS

The following principles and concepts form the foundation of the Being Least Intrusive tool. Responding to situations of abuse and neglect of vulnerable adults is a complex endeavor. In the context of vulnerable First Nation adults, this work presents additional challenges. Integrating knowledge and awareness of the following principles and concepts is critical in assisting front-line workers to develop a way of being in practice that facilitates encounters and experiences that reduce risk and vulnerability, and protects the dignity of the client.

Least Intrusive Most Effective

Embedded in the BC Adult Guardianship Legislation are guiding principles intended to assist front-line workers balance the responsibility to intervene, support and protect vulnerable adults with the often competing ethical responsibility to respect and protect an adult’s rights of autonomy and self-determination. Two critical principles are:

  • Adults are presumed capable and have the right to choose for themselves how, where and with whom they want to live—even if that means living at risk.
  • All adults should receive the most effective but least intrusive form of support, assistance and protection when they are unable to care for themselves and/or their assets.

Cultural Safety

Cultural safety, a term first used in New Zealand in reference to health care service with the indigenous Maori people, is an outcome reflected in the qualitative experience of the client. The client determines whether s/he has felt that her/his cultural identity, values and preferences have been respected and taken into account in the care provided and decisions made.

Cultural Safety is predicated on:

  • Respectful relationships & Equitable partnerships
  • Strengths-Based & Collaborative problem-solving and decision-making
  • Thoughtful, Intentional and Meaningful action

Vulnerability and Capability

Issues of vulnerability and capability are at the heart of adult abuse and neglect investigations and central to adult guardianship and substitute decision-making legislation. They are complex individual and interconnected concepts:

  • Vulnerability is a social condition: it emerges from and in relation to interconnected factors such as poverty, isolation, ageism, physical and/or mental illness, education, disability, gender and culture.
  • Capability refers to specific tasks and particular categories of decision-making: a person may be capable of certain tasks and decisions but no longer capable of others.
  • Vulnerability and Capability are both dynamic; they can fluctuate depending on circumstance.

Attention to an adult’s social environment and the factors that contribute to vulnerability is critical in giving meaning to the notion of capability and informing responses that are least intrusive and most effective.

Aboriginal Worldview and Understanding of Health

The aboriginal understanding of health and wellness stands in stark contrast to the definition of health in mainstream healthcare. Central to aboriginal worldview is the belief in the interconnectedness of all things in existence and reverence for the intrinsic wholeness, sacredness and value of self and others.

Health and well-being is understood holistically across multiple and interconnected dimensions. It is inclusive of and determined by the connection and balance between and within:

  • The Total Person (body, mind, heart, spirit; across the lifespan: child, youth, adult, elder);
  • Their Total Health (physical, emotional, mental and spiritual); and
  • The Total Environment (family, community, social, cultural, economic, natural world).

The concepts that define and determine one’s experience of health and well-being include: wholeness, balance, connection or relationships, harmony, healing, learning and growth.

Meaning Centred Practice

Meaning centred practice is

Inquisitive: front-line worker engages as ‘humble knower’, curious about the client’s worldview, meanings and lived experience.

Collaborative: front-line worker engages in a reciprocal process of sharing knowledge and exploring meaning.

Respectful: front-line worker honours diverse ways of knowing and being; creates space for voice, wisdom and experience of the client to emerge, be heard, be valued and understood.

Critical: front-line worker engages in critical self-reflection —cultivating an awareness of how social and cultural identity and experience shape knowledge, awareness and interactions.

BEING LEAST INTRUSIVE: THE TOOL

Being Least Intrusive is a concrete tool that front-line workers can use to guide them through a process of critical preparation, assessment and reflection. It is divided into three sections, each with a series of questions that will assist front-line workers to develop a critical self-awareness, gather information that will inform a more holistic assessment, and engage with clients, families and communities in ways that are culturally safe and appropriate.

Orientation to Self

When: prior to engagement

Action: developing a critical awareness of self: attitudes, values & assumptions, social location & power.

Orientation to Context

When: before and throughout client engagement

Action: orienting to culture & community, gathering case information in context of holistic assessment.

Orientation to Reflection Process

When: after client/family/community engagement

Action: debriefing case; gathering feedback about engagement; improving practice.

ORIENTATION TO SELF:

When: prior to engagement

  1. Who am I (personal and professional role, socioeconomic status, cultural affiliations, worldview, etc)?
  2. What are my attitudes and assumptions about the issue of abuse, neglect and self-neglect of vulnerable adults, of vulnerable First Nation adults?
  3. Will any of my values or biases impede my role/responsibility in creating a safe environment or safe encounter for the client/family with whom I am working?
  4. Who am I in relationship to the client, family, community with whom I work? (How do they see me? understand my role? What is the power differential?)

ORIENTATION TO CONTEXT

Community & Culture

When: before case work begins

  1. What are the resources within the community (social & health care services)?
  2. Are there specific protocols of engagement (e.g. cultural traditions, values) with/within this community that I need to be aware of and incorporate?
  3. Who can I partner with in this community – who is the most appropriate person (has a knowledge and connection to the client/family, is in a position of trust, can act as a cultural guide and can assist in developing a culturally safe and appropriate support and assistance plan?)
  4. What is the history of engagement, collaboration that my organization (e.g. community health agency) has had with this specific community regarding service delivery?

Case Specific

When: prior to engagement with client/family/community

  1. What are the objective details of this situation? (What are the facts, what is the specific concern reported, who is involved?)
  2. Who reported the concerns of abuse & neglect (e.g. family, client, community member, service provider) and what is their connection to the situation?
  3. Will my involvement with the client/family/community be welcome?
  4. How will I engage others and still respect the confidentiality, privacy, and dignity of client and family?

Gathering Information

When: over the course of multiple interactions with the client and involved family, caregivers, and service providers

  1. How does the client experience his/her own Physical, Mental, Emotional and Spiritual Health?
    • What are the words they use to describe their current state of well-being and functioning across these dimensions?
    • How do they make sense of the current situation?
    • Do they have any specific concerns about any aspects of their health and well-being?
    • How do the client’s perspective, experience and meanings differ from those of their family, caregivers and service providers?
  2. What is the client’s experience of connection and belonging to:
    • Family (who is important to them, what is their role within the family),
    • Community (what is important, what is their role within their community)
    • Culture (traditions, values, spiritual practices)

Assessment

When: after as much information as possible/relevant is gathered

  1. What are the specific factors in the following holistic dimensions that contribute to the client’s strength and vulnerability?
    • Physical well-being (physical functioning, health, activity)
    • Mental well-being (cognitive functioning, mental health, learning/education)
    • Emotional well-being (self-esteem, sense of control over forces affecting one’s everyday life, livelihood, health)
    • Spiritual well-being (cultural identity, engagement, integration of past/present)
    • Relationships (connection and belonging to family, extended family, community, land, creation)
    • Social well-being (income, security of food and shelter, language, access to support and resources)
  2. How will I distinguish my understanding of health and well-being from those of the client, family, and community?
  3. How will I distinguish my values regarding standards of care, family relationships, and physical surroundings from those of the client, family, and community?

ORIENTATION TO REFLECTION PROCESS

When: after intervention; happens over time

  1. Was I least intrusive/most effective in my intervention? (e.g. was the client’s autonomy and self-determination respected and balanced against the need for support and assistance?)
  2. Was my involvement experienced by the client as culturally safe? (was the client’s cultural identity, values and preferences taken into account in the service encounter; was the client engaged in the encounter; was the client involved in developing a respectful and appropriate support and assistance plan; did the client welcome my involvement; was I invited back?)
  3. What did I learn about myself (were my values and assumptions about the situation, client, culture challenged?)
  4. What has the feedback been that I have received from the client, family, community, colleagues about the process?
  5. How could my practice improve?

References & Additional Information

Foundational Principles

Cultural Safety

Ball, J. (2008). Cultural Safety in practice with children, families and communities. Early Childhood Development Intercultural Partnerships, University of Victoria. Victoria, BC. Retrieved from www.ecdip.org/culturalsafety/

Poster at www.ecdip.org/docs/pdf/cultural%20safety%20Poster.pdf

Being Least Intrusive

Background to approach in: Struthers, A., L. Neufeld. (2010). Being Least Intrusive: an orientation to practice in responding to situations of abuse, neglect and self-neglect of vulnerable First Nation adults (Working Paper). www.bccrns.ca/projects/index.php

Vulnerability & capability

BC Adult Abuse/Neglect Prevention Collaborative. (2009). Provincial Strategy Document: Vulnerability and Capability Issues in BC. Retrieved from www.bcli.org/ccel/projects/vanguard

Aboriginal Framework

Adopting a social determinants of health lens, the Assembly of First Nations (AFN) developed a holistic policy and planning model to highlight gaps in First Nation well-being and identify broader explanatory factors to assist in developing actions and responses to more effectively address and improve the health of First Nation people. Underpinning this model is a cultural framework, based on indigenous knowledge, values and beliefs, that defines health and well-being as an integration of ‘total health’, ‘total person’ and ‘total environment’.

Reading, Jeffrey L., Andrew Kmetic, Valerie Gideon. (2007). First Nations Wholistic Policy and Planning Model: Discussion Paper for the World Health Organization Commission on Social Determinants of Health. Assembly of First Nations, Ottawa, Ont. Available from: http://ahrnets.ca/files/2011/02/AFn_Paper_2007.pdf

Meaning Centred Practice

Janet Clark offers a research based approach to co-creating meaning across cultures. Clark, J. (2006). Listening for Meaning: A Research Based Integrative Model for Attending to Spirituality, Culture and Worldview in social work practice. Critical Social Work, Vol. 7, No. 1.

Abuse & Neglect tools

Flowchart of Intervention: a graphic mapping of tools and resources within a process of response to situations of abuse and neglect within on-reserve First Nation communities. The process of response itself can be helpful in guiding front-line workers in their response to concerns of abuse and neglect, as well as assist communities build capacity, identify strengths, resources and service needs, and develop a coordinated, community response.

In: Promising Approaches for Addressing / Preventing Abuse of Older Adults in First Nations Communities. Available at: www.bccrns.ca/projects/docs/promising_approache_asdressing_ preventing_abuse.pdf

First Nation Re:Act: Assessment and reporting information/ process for investigating reports of adult abuse and neglect, adapted for use with First Nation’s individuals and communities across Canada.

Available at: www.vchreact.ca/

ACKNOWLEDGEMENTS:

The development of this orientation to practice would not have been possible without the direct learning that has emerged from front-line work and the wisdom and knowledge that has been shared by our First Nation colleagues, community leaders and engaged individuals through dialogue and example, in practice and in partnership. We are grateful for the support, guidance, feedback and joint exploration that have come from the following:
BC Association of Community Response Networks
Wit Works Ltd.
VIHA, Home and Community Care Program, Campbell River
Kwakiutl District Council - Health Programs

While the tool is specifically directed towards non-aboriginal front-line workers providing services to vulnerable adults in onreserve First Nation communities, we have received feedback from a variety of service providers, community agencies and involved community members who are interested in using the tool to enhance practice, build capacity and more effectively and safely engage with individuals, families and communities in their service environments; including:
Police
Child Protection Agencies
Financial Literacy Projects
First Nations and Aboriginal Communities

© September 2011 April Struthers and Lindsay Neufeld. The authors can be contacted at witworks@dccnet.com and lindsayneufeld@mac.com respectively

This information prepared in conjunction with Wit Works, the Government of Canada's, Networks of Centre of Excellence and Human Resources and Skills Development, and NICE.

Link: BLI.pdf...