CONFIDENTIALITY AND RISK ASSESSMENT: CASE STUDIES OF THE PROFESSIONAL JUDGEMENTS OF NURSES, SOCIAL WORKERS AND HOSPITAL CHAPLAINS Florence Anne Watson Submitted in accordance with the requirements for the degree of Ph.D. in Social Policy The University of Leeds Department of Sociology and Social Policy September 1998 The candidate confirms that the work submitted is her own and that appropriate credit has been given where reference has been made to the work of others. 1 ABSTRACT This research examines the relationship between professional codes of ethics and ethics in practice. Key issues explored include: (a) to what extent do professionals use their ethical code when making decisions involving ethical dilemmas; (b) how frequently do they disclose information against clients' wishes and how is this justified; (c) are professional judgements so consistent that a common practice standard can be determined; (d) what differences in decision-making exist between nurses, social workers and chaplains and is this related to the extent of 'professionalization' of the occupation into an integrated network? Vignettes describing low-risk community mental health cases, posing ethical dilemmas for the research participants about the disclosure of confidential information, were used as a focus for lengthy semi-structured interviews with 27 nurses, 21 social workers and 7 chaplains. Data was collected about respondents' professional membership and understanding of legal/professional/employer guidance about confidentiality. Responses were analyzed in relation to themes of 'consistency', 'conflict of loyalties', and 'rationalization' of choices. Confidentiality was breached more than it was maintained, although there were considerable differences both within and between professional groups about the points of disclosure. In addition, no standard recipients for information could be determined. Vignettes were sometimes interpreted differently. Disclosure was justified through loyalties conflicting with responsibilities to the named client. This included loyalty to fellow professionals, to third parties, and to oneself. Disclosure could be motivated by desire to obtain a 'good result'. Participants displayed generally poor knowledge of legal/professional/employer frameworks for decision-making, and referred to their codes of ethics rarely as a reason behind decisions. 2 Implications for professional training and employer policy are discussed. Problems in professional accountability are raised, for practitioners, professional bodies, and employers. The utility of a code of ethics which espouses a standard of confidentiality so far removed from day-to-day practice is questioned. 3 ACKNOWLEDGEMENTS Many thanks are due to the four members of the Department of Sociology and Social Policy who supervised my research and the writing of this thesis. Dr. Ray Pawson helped me to develop and refine the vignettes used in the interviews. Professor Alan Deacon was most encouraging and positive about my early struggles to write, and without his help I never would have decided on a title. Dr. Malcolm Harrison and Dr. Geoff Mercer provided valuable detailed comments about drafts, helped me to locate the research within a theoretical framework, and reminded me about references. In addition, I must thank my mother, Dr. Cicely Watson, Professor Emeritus at the Ontario Institute for Studies in Education, for her continued intellectual encouragement and all those informal 'tutorials' over the breakfast table, as well as comments on draft chapters. Thanks are also due to my 87 year old father who kept reminding me of deadlines, saying how much he wanted to see me complete this before he "shuffles off this mortal coil". For most of the last five years I have been working part- time as a social worker for the Department of Social Services, Leeds City Council, which gave me leave of absence for several months so I could write the thesis. Thanks are also due to my colleagues at Buckingham House, who have expressed (sometimes slightly bemused) interest in my research. I wish to thank the Department of Social Services in Wakefield and the Leeds Community and Mental Health Service Trust for assisting me to contact social workers and nurses. I am also immensely grateful to the people who agreed to be interviewed. Without their patience and extraordinary cooperation, this research would have been impossible. 4 TABLE OF CONTENTS Abstract: 1 Acknowledgements: 3 Table of Contents: 4 List of Tables: 5 Chapter One: Introduction 7 Chapter Two: Professions and Professionalization 24 Chapter Three: Professional Ethics, Professional Development, and Professional Identity 43 Chapter Four: Ethical Dilemmas in Nursing, Social Work and the Chaplaincy and Boundaries of Confidentiality 66 Chapter Five: Research Questions and Methodology 92 Chapter Six: Professional Background of Respondents 123 Chapter Seven: Consistency 132 Chapter Eight: Conflicting Loyalties 169 Chapter Nine: Rationalization 208 Chapter Ten: Framework for Decision-Making 223 Chapter Eleven: Conclusion 236 Bibliography 264 Appendix One: Vignettes and Interview Questions 284 Appendix Two: Example of an Interview Transcript (Excerpt) 294 5 LIST OF TABLES Table One: Age Distribution of Respondents by Profession 124 Table Two: Sex Distribution of Respondents by Profession 125 Table Three: Professional Qualifications of Respondents Distributed by Profession 127 Table Four: Degree Qualifications of Respondents Distributed by Profession 128 Table Five: Years of Experience Distributed by Profession 130 Table Six: Number of Years in Current Post Distributed by Profession 130 Table Seven: Distribution of the Points of Disclosure (version 1, 2, 3, etc.) of Vignette One by Professional Group (Number and Percentage) 136 Table Eight: Distribution of the Points of Disclosure (version 1, 2, 3, etc.) of Vignette Two by Professional Group (Number and Percentage) 138 Table Nine: Distribution of the Points of Disclosure (Version 1, 2, 3, etc.) of Vignette Three by Professional Group (Number and Percentage) 140 Table Ten: Distribution of the Points of Disclosure (Version 1, 2, 3, etc.) of Vignette Four by Professional Group (Number and Percentage) 142 Table Eleven: Distribution of the Recipients of Information in Vignette One by Professional Group (Number and Percentage) 147 Table Twelve: Distribution of the Recipients of Information in Vignette Two by Professional Group (Number and Percentage) 150 Table Thirteen: Distribution of the Recipients of Information in Vignette Three by Professional Group (Number and Percentage) 151 Table Fourteen: Distribution of the Recipients of Information in Vignette Four by Professional Group (Number and Percentage) 154 Table Fifteen: Distribution of Decisions to Maintain Confidentiality by Vignette and Professional Group 173 Table Sixteen: Distribution of Reasons Given for Disclosure by Professional Group 180 Table Seventeen: Distribution of the Frequency of Main Reasons to Disclose by Vignette 181 6 Table Eighteen: Distribution of Rationalizing Statements, Statements Acknowledging Conflict, and Inferred Acceptance of Conflict in Vignette One by Professional Group 211 Table Nineteen: Distribution of Rationalizing Statements, Statements Acknowledging Conflict, and Inferred Acceptance of Conflict in Vignette Two by Professional Group 212 Table Twenty: Distribution of Rationalizing Statements, Statements Acknowledging Conflict, and Inferred Acceptance of Conflict in Vignette Three by Professional Group 214 Table Twenty-one: Distribution of Rationalizing Statements, Statements Acknowledging Conflict, and Inferred Acceptance of Conflict in Vignette Four by Professional Group 215 Table Twenty-two: Awareness of Legal Framework by Profession 226 Table Twenty-three: Numbers of Areas of Law Identified by Each Profession 227 Table Twenty-four: Professional Association Membership by Occupation 229 Table Twenty-five: Awareness of Professional Guidance by Occupation 230 Table Twenty-six: Awareness of Employer's Guidance by Occupation 232 7 CHAPTER ONE INTRODUCTION This thesis investigates the relationship between the nature of professionalization and the development of degrees of professionalism. Specifically, it explores (1) the role of a profession's formal code of ethics and what might be termed its practitioners' "ethics in practice", and (2) the influence that the imperatives stated in the code have upon decisions taken in daily work as professionals encounter situations involving ethical dilemmas. Such dilemmas were investigated by reference to common practice situations in three of the 'caring professions' (nursing, social work and the chaplaincy). Specifically, I wanted to explore certain issues: 1. To what extent do professionals use their ethical code to assist them to make decisions which involve ethical dilemmas? What alternative ethical framework do they use? 2. How frequently do professionals disclose information against clients' expressed wishes and how do they justify these decisions? 3. Are professional judgements consistent to such a degree that a common accepted practice standard (to which practitioners should generally adhere) can be determined? 4. What differences in decision-making exist between the three professions, and is this related to the extent to which each profession is "professionalized" and integrated into an closely knit inter-professional network? 5 What implications do the research results hold for professional accountability, and the development of each occupation and for policy-makers?