Ethical dilemmas in professional practice in anthropology
Policy - environment - development
Worked example 1: HIV/AIDS in Lothian
Interview with a Community Psychiatric Nurse
This page reproduces an interview undertaken by Dr Guro Huby with a Community Psychiatric Nurse. The names of hospitals, care centres and staff have been changed to ensure anonymity.
Q. Brian, you are a community psychiatric nurse in a team of CPNs who work specifically with people with HIV and AIDS. Could you first tell me a little bit about the work of a CPN in general terms?
A. A CPN works obviously in this case with people who are HIV positive but generally it's with people who need counselling, help with negotiation services, with various other agencies, and general help with daily living, to help them cope better with whatever particular mental health problem they are dealing with at that moment.
Q. And how does your team work with people with HJV and AIDS?
A. Well, we all in the team have a case load of clients, and we receive referrals from local hospital, GPs, district nurses, health visitors, social workers, we also receive self referrals, we've got an open referral system.
Q. How many members does your team have?
A. There are six community psychiatric nurses in our team, a team leader and five others.
Q. How do you divide the work between you?
A. We take referrals on a sector basis, depending on what area of the X Hospital the person lives and that usually balances itself out. We all get fairly even case loads.
Q. But could you tell me more specifically what kind of work you do with your clients with HIV?
A. Yes, this can involve counselling, adjustment which usually involves adjusting to living with HIV.
Q. What does that involve?
A. That involves readjusting, helping someone to readjust their lives to the stresses of living with a 'terminal' illness. In this particular case because people already live with such numerous amount of problems, HIV is an added stress already on usually a burdensome life, and can often be the factor that topples all others, or underpins all others in anxiety.
Q. And could you tell me a bit more about what these other problems are?
A. Well, our clients have numerous social problems, usually, unemployed, poor housing, quite often poor health apart from HIV, poverty.
Q. So it sounds as though you work with quite a specific target group. There must be people who have HIV who have not got these problems?
A. Yes we tend to work with a more chaotic group within the HIV field. This group tends to be drug users, they need a lot of help and direction to deal with their daily lives.
Q. It sounds like quite hard work
A. Yes it is hard.
Q. And could you tell me a bit about how you liaise and co-operate with other services your clients might use, like hospitals, social services etc.?
A. How we liaise. Well we attend meetings at the local hospital where all other professionals are available for discussion, multi-disciplinary discussion, and specific clients and patients are discussed at these multi-disciplinary meetings.
Q. You have talked to me in the past about how it's sometimes difficult to work out who does what with these clients. Could you tell me a bit about how that works?
A. Yes in the past it's been quite difficult, a lot of HIV services were on the go more than they are now. People were so concerned, workers in the other fields were so concerned that HIV was such a big problem, and so stressful for them as well as the clients, that they referred to more than one agency to try and somehow make life better for these particular people. Unfortunately that often led to the chaos that the clients already had in their lives, and one particular noticeable feature in working with people who are particularly chaotic, is that, in this group anyway, it can often split people into who gets told different information, and often this leads to workers fighting amongst themselves because of all the different information from the client.
Q. So the workers compete about who is right, who has got the right information?
A. Yes, that's right.
Q. And has that got better, how do you cope with that?
A. That's got much better, thankfully, I think we've all learned from this process, the process of the chaos of the client, whatever is projected out from the client. This has also been helped by the multi-disciplinary meetings that we have at the local hospital. People are openly discussed, people discuss clients, and we are also trying to establish a multi-sex social register where only one organisation receives a particular client, and that's also because of the funding, and restrictions, it's also a beneficial move.
Q. So you use resources more efficiently?
Q. Moving on from that, could you tell me how the changes in client population and also how the changes in funding and organisation of mental health and social services is affecting your work at the moment?
A. Our money is ringfenced, HIV money is ringfenced at the moment, but this will be coming off next April, this means that along with the fact that our client population referrals are diminishing we would like to do some multi-disciplinary work in another directorate. At the moment our directorate organisation in the hospital and community is all being changed. We could either join the directorate involved with addictions, or psychological therapies, and we are hoping to move to psychological therapies as we feel that this is the area the service can best utilise the skills we've built up with this client group over the past few years.
Q. And what will that change of directorate involve?
A. It will involve new management, the clinical director would be a psychologist, rather than a consultant psychiatrist, and be obviously a psychologically led service. And maintain the direction of psychosocial rather than purely psychiatric.
Q. So it would be defined as psychosocial and not necessarily as medically defined mental illness?
A. Yes, much less psychiatrically defined, people who don't have a definable mental illness.
Q. Yes, and you would take all kinds of general referrals, of people with mental health problems, not limit it to one specific area?
A. Yes, that's right. This has always been an area of contention, between psychiatry and primary health care, but psychiatrists only see people with mental illness, and therefore there's a large identifiable gap, and we are hoping to help fill that gap. We're working using this particular model.
Q. OK, in conclusion, could you tell me a little bit about, in your experience, and in your view, what kind of client groups with HIV miss out on services at the moment?
A. People with dementia miss out at the moment because there is no safe place where these people can be. People with dementia quite often are left on their own, are not seriously ill enough to warrant being in a psychiatric establishment, and therefore people are very reluctant to hold these people against their will, not against their will, but in a place of safety and encourage them to stay in a place of safety. At the moment it is all open doors, no one wants to be the authority figure, and lay down the law as it were and say that these people are unsafe, that their safety is at stake.
Q. Anybody else that you think is missing out?
A. Yes, I was at a conference recently regarding HIV and the way forward and at the conference it was stated that there was a gap in the service for gay men, but in my opinion we would have to have a needs assessment done, there doesn't seem to have been one done recently. Because we in the service would work with gay men, but we don't really get referrals from gay men. Also colleagues in other settings, who work more with gay men than we do, their referrals are down also, so a needs assessment would be vital, one which would be distributed or increased.
Q. Any other problems?
A. Other problems from the client group that we traditionally work with are people with social problems, people who are still living in poor housing conditions, large areas of multi-deprivation, and it's unfortunate that people have to be ill to get a house in a decent area, and as one of the researchers pointed out time and time again, that people who live in poor social conditions and poverty suffer more than the other members of the population.
Q. Thank you very much Brian.