Pruebas de calidad y desempe˜ no del sistema

O‟ Sullivan (1999) defines decision-making as a process of constructing a choice. Decision-making occurs where there is some degree of recognition of a need or a desire to make a choice.

Making decisions is an inherent part of social work practice no matter what the specific practice field or task. Social work decisions are often problematic balancing acts based on incomplete information, time constraints, pressure from different sources, uncertainty as to the likely outcome of the different options, and the constant fear that something will go wrong and being blamed (O‟

Sullivan, 1999).

Ethical decision-making models are systematic ways of thinking through ethical dilemmas. Every model is based on underling value assumptions derived from a specific or several philosophical approaches on ethics. Therefore, a model should not be chosen uncritically. On the contrary, social workers need to acknowledge the strengths and limitations of the ethical theories that underpin these models. An ethical decision is a process that entails the effort to balance social work‟s values, (i.e. making moral judgments), the consideration of the goals and responsibilities of social work‟s profession, and a decision about how to act (Bowles et al., 2006).

Irrespective of the ethical decision-making model that practitioners use for solving their dilemmas, ethical awareness is seen as a primary skill for social workers. This awareness is referred to as a condition where the practitioner is aware of the ethical principles underlying their actions and encounters, and ethics as live elements within their practice. Ethical action is the result of the practitioner‟s ethical consciousness/awareness (Speicher, 1998). In fact, Reamer (1982) and Speicher (1998) suggest that for social workers to be able to analyze dilemmas in a thoughtful and systematic fashion, they need to be able to understand the various strategies that derive from philosophical approaches on ethics. Furthermore, they need to be able to acknowledge the strengths and limitations of these approaches as they represent specific methods for justifying values. Additionally, social workers should be able to see ethical dilemmas or issues not as a crisis, but as an opportunity to improve the ethical framework within their practice. To obtain this view of ethics, social workers should be skillful in critical reflection.

Critical reflection requires a high level of personal awareness so they can recognize prejudice or personal interpretations and ideas involved in professional practice. It also requires an ability to critically analyze the environment and the political context that structures ethical decisions.

Overall, the purpose of critical reflection is to improve professional practice by identifying deep-seated assumptions such as previously unquestioned cultural norms. The reflective process is focused on power and it is linked with the basic ideas of critical theory. In this sense, critical reflection must incorporate an understanding of personal experiences within social, cultural and structural contexts (Fook and Askeland, 2007; Bowles et al., 2006).

There is a growing interest on social work ethics and an extensive theoretical literature already exists. However, scant empirical research has been conducted on ethical decision-making (Jansson and Dodd, 1998). Bowles et al. (2006) also argue that there is a poignant lack of any research into whether ethical decision-making models work.

In particular, a body of three empirical studies looked at the nature of ethical dilemmas that social workers deal with in various settings. All studies, except one, used qualitative approaches and participants were not guided to reflect on predetermined ethical dilemmas. Despite the variety of social work settings and ethical contexts, similarities in the responses of social workers can be detected. In particular, Conrad (1988) with a survey in the US and McAuliffe (2005) using a qualitative approach in Australia, found that among the most serious ethical dilemmas experienced by the social workers were those that involved conflicts between organizational and professional values, as well as funding constraints or policy issues. Conrad (1988) also determined that the intervention phase of the social work process produced the greatest number of ethical conflicts with issues around confidentiality. Contrarily, Banks and Williams (2005) who qualitatively explored the nature of ethical dilemmas of social workers, and youth and community workers in the UK found several main ethical issues/ dilemmas including issues relating to how much choice service users should exercise, the rationing of time and resources, and maintaining professional integrity.

Three studies also indicated that overall, social workers were not able to use ethical language, and they could only broadly identify their ethical dilemmas and/or problems. In particular, Kugelman (1992) qualitatively explored the role that social work ethics plays in informing social work behavior as compared to other influences of an extra-ethical nature. A fictional case was used about an old woman, with cancer and a psychiatric history, who refused an operation. The majority of the social workers did not rely on an ethical analysis of the dilemma. However, those who analyzed the dilemma on ethical grounds appeared to be guided by their commitment to self-determination, and more importantly, they persevered in advocating for the patient. In contrast,

those who relied on technical considerations discontinued advocating. Similarly, Banks and Williams (2005) found that only one small proportion of social work students articulated an ethical dilemma as a conflict of values that involved alternative choices. In addition, students‟ accounts had no elements of decision-making. In fact, the researchers noted that students referred to broad issues, such as drugs and alcohol or physical conduct, for the description of ethical dilemmas. Moreover, McAuliffe (2005), using an action research model, implemented the concept of Reamer‟s ethical audit¹ in 11 organisations in Australia and recorded the outcomes. The researcher found that participants admitted that their involvement in the study marked the first time they had to think about and discuss ethical issues in practice. Specifically, practitioners claimed this was the first time they used ethical language, and the first time they began to see various and differing perspectives on controversial situations. The ethical audit procedure also demonstrated that it was an effective tool for the review and modification of the policy relevant to daily practice, and therefore deemed to enhance the quality of services.

In terms of the impact of ethical dilemmas on social workers, two studies have indicated various short and long term effects in their personal and professional lives. McAuliffe (2005) interviewed thirty Australian social workers and found several difficult emotional conditions associated with the experience of an ethical dilemma. These emotional conditions included stress, depression, agitation and irritation, isolation, overwhelming feelings, paranoia, anger, frustration and decreased tolerance for both clients and colleagues. An important emotional condition was also associated with feelings of “unfinished business”. Some physical symptoms were also expressed by participants. The most common physiological response reported was physical exhaustion.

Other physical symptoms described by participants were insomnia, high blood pressure and immune system problems. The same emotional conditions as a result of ethical dilemmas were also noted by Banks and Williams (2005). As far as the long term impact of ethical dilemmas is concerned, McAuliffe (2005) found that the participants identified impacts on their attitudes and awareness, practice, and personal relationships. In concrete terms, some acknowledged the value of the social work profession; however, some discredited the humanitarian role of social services organizations. For others, the realization of the political and power dynamics had a positive impact to strengthen their personal commitment to social work. There was also an increased awareness of the importance of the clarified roles and responsibilities in the workplace and a greater awareness of the importance of boundaries issues in relation to clients, colleagues

1 Reamer‟s ethical audit is a method that examines the familiarity with known ethics- related risks in practice as well as the organisation‟s procedures and protocols for handling ethical issues, dilemmas and decisions.

and managers. It was important to note that four social workers made the decision to leave direct client work as a result of the long term impacts of ethical dilemmas, while another four left their respective places of work with feelings of „unfinished business‟. The social workers who resigned from their job or from the profession had little support either from colleagues or supervisors at the time of experiencing the ethical dilemma.

Findings from the study of McAuliffe (2005) also indicated that participants used a variety of mechanisms in order to be able to cope with stressful ethical dilemmas. Some tried to make light of the incident with humour and others were attentive to physical fitness and self care. Another strategy employed by other social workers was to focus on tasks that needed to be achieved on a daily basis so that the bigger picture would not become overwhelming. Yet others denied the reality of the situation by ignoring the case and moving to another case or by using more extreme forms of denial. Social support was proved to be a very important factor involved in the ethical dilemmas, as many of the participants who felt considerably isolated in their places of work and who experienced high levels of stress were simultaneously unable to access good social supports. Conversely, negative effects were fewer for those who had good social supports and they were able to work through the ethical dilemma quickly.

One study, although not particularly concerned with the exploration of social work ethical dilemmas, importantly indicated the value preferences of the social workers. As ethical decision-making involves moral judgements these findings indirectly suggest possible factors related to ethical decisions. In particular, Furman et al. (2007) who qualitatively explored potential ethical dilemmas as a result of an immigration law found that only few MSW and BSW responded to macro level concerns, while social justice and community organisation intervention were notably missing from the data.

The value preferences of social workers are considerably important especially when related with the findings of a qualitative study that illustrated the ways that individual ideologies and beliefs impact social work practice. In particular, Sullivan (2008) explored social work practice with older people in UK community care. Findings of this study indicate that social workers‟ ideologies and perceptions dictated their practice while different meanings introduced by their clients were ignored. More importantly, social workers‟ perception of their duties appeared to be originated and controlled by organizational rules and policy. At the same time, social work ethics appeared

to be loosely applied and clients were excluded from the ethical decision-making of the social workers.

The attitudes and beliefs of US social workers about sexual involvement with clients were quantitatively explored by two studies. Jayaratne et al. (1997) found that 43.7% of the social workers believed that feeling sexually attracted to a client was appropriate, and 52.4%

acknowledged feeling sexually attracted with their clients. However, only 1.1% of the social workers declared having sex with a former client. In contrast, Mittendorf and Schroeder (2005) using an exploratory survey found that all of their respondents believed that erotic contact between social worker and client was usually harmful to the client and always inappropriate.

However, many of the social workers (54%) affirmed that they had clients who reported having had sexual contact with a previous therapist. These respondents acknowledged having had a total of 245 clients who reported having sex with their previous therapists. Importantly, of those social workers who believed that one or more peers had initiated sexual contact with clients, only 15% reported these violations of ethics to an ethics committee or licensing board. This finding is considerably important as whistle blowing is currently considered as one of the ethical responsibilities of social workers which is related to their ethical obligation to protect their clients from malpractice. However, there was no empirical study examining the issue of whistle blowing and whether social workers ethically embrace whistle blowing practice.

Importantly, the above studies detected several factors related to the development of social work ethical dilemmas, however, in various contexts. Policy issues, cost-effectiveness and organisational values appeared to be strongly involved. Nonetheless, further research is needed in order to understand the factors effecting the ethical decision-making process of the social workers. In addition, some studies indicated that, overall, the ability of social workers to ethically analyse their cases possibly leads to a stronger engagement with advocacy and recognition of important factors (i.e social policy, organisation rules) that affect practice. However, there are no studies exploring why social workers do not acknowledge conflicts in values in the first place or their prior education on social work ethics. In addition, further research is needed to explore the role of social workers‟ ideologies and/or value preferences that impact on ethical decision-making.

Although two empirical studies indicated the emotional impact of ethical dilemmas on social workers, there are no studies indicating the ways that emotions affect the ethical decision-making

process. However, studies have clearly shown that social workers dealing with ethical dilemmas experience difficult emotions. Therefore, it is anticipated that these emotions may function during the whole process of decision-making and consequently affect the decision or the action that social workers take.

Although these studies were not focused in the exploration of the nature of the social workers‟

ethical dilemmas, some assumptions are worth noting. The fact that some social workers who experienced ethical dilemmas ended up discrediting the humanitarian purpose of social organisations, strengthens previously discussed studies which indicated that organisational values and policy in contrast with professional values are one of the major sources of ethical dilemmas for social workers (McAuliffe, 2005; Conrad, 1988).