Essays and Assignments from the Pen of a Student Psychiatric Nurse 2

In order to ensure that health care delivery is of the highest possible standard, the U.K. Government (DH 2003) has highlighted a number of fundamental aspects of care, including 'Privacy and dignity'. With reference to relevant literature and clinical placement experiences in your own branch and at least one other practice setting, explore how nursing contributes to the achievement of best practice in this aspect of care.

This essay will address the perspectives and aims of the ‘privacy and dignity’ benchmark, as outlined in the Department of Health’s Essence of Care (2001b, 2003) document, taking into account its strengths, shortcomings and implications for ‘best practice’. First, the content of the benchmark factors themselves will be examined, both in relation to other key benchmarks and in light of my own experiences on clinical placement. Second, some of the problems associated with the definition of the concepts of ‘privacy’ and ‘dignity’ will be considered, with a view to clarifying their vital importance for the nursing profession.

Of the eight areas of care featured in the first edition of the Essence of Care (2001) the ‘privacy and dignity’ benchmark stands in marked contrast to most others (e.g. ‘pressure ulcers’ and ‘continence and bladder and bowel care’), because it is relatively vague. Moreover, although ‘privacy’ and ‘dignity’ are, broadly speaking, ‘taken-for-granted’ ideas there is little doubt that such terms can have little explanatory power when isolated as abstract concepts. Nonetheless, the Department of Health’s ‘toolkit for benchmarking the fundamentals of care’ aims to go some way towards indicating how these important principles can be made concrete in the delivery of healthcare.The Essence of Care benchmark for privacy and dignity is constructed around seven key factors and benchmarks of best practice, which can be summarised as follows: personal identity; personal boundaries; communication; confidentiality; availability of private areas; and attitudes and behaviour (of staff). The nebulous quality of some of the preliminary indicators of ‘best practice’ seem to reinforce the impression that, at the point of publication, privacy and dignity policies were underdeveloped. For instance, regarding the ‘attitudes and behaviours’ (of staff) the benchmark of best practice announces that ‘patients [should] feel that they matter all of the time’. It is surely easy to see how such an imperative might be considered glib and patronising. Research shows (and this author’s experience confirms) that, just as patients ‘expose themselves to hospital staff, and possibly other patients, to a degree that would not be acceptable in normal life’, they also accept that there is, necessarily, a system of priorities in healthcare that dictates that some cases ‘matter’ more than others at certain times (Malcolm 2005: 12; Scott et al. 2000: 566).

These doubts aside, of the remaining introductory summaries the majority of the benchmarks appear, on first reading at least, to be placed on surer foundations. Thus, in relation to ‘privacy of patient-confidentiality of client information’ (a topic to which this essay will return) the benchmark demands that ‘patient information is shared to enable care, with their consent.’ Similarly, the guidelines insist that ‘patients’ care actively promotes their privacy and dignity, and protects their modesty.’ In addition, together with the making available of ‘an area for complete privacy’, the above advice on ‘privacy, dignity and modesty’ is linked to the question of ‘personal boundaries and space.’ Here, in between uncontentious references to personal contact/touch and disturbing/interrupting patients, attention is drawn to the question of segregated/single-sex facilities. However, this author’s experience on placement, in conjunction with literature on the subject, confirms that there is a notable mismatch between many of the ideals promoted in Department of Health’s official guidelines ‘and the soft messy ground of practice’ (Manthey 2001: 5).

In addition to addressing the conflict between patient dignity and staff safety in the moving and handling of patients, Scott (1997, 2004) has highlighted the practical (not to mention financial) problems of implementing single-sex bays in hospitals. She points out, for instance, that ‘a partition designed to restrict patients’ view will restrict nurses’ view and may impede the delivery of safe patient care’. Unfortunately, the Essence of Care privacy and dignity benchmark does not properly tackle this tension between privacy and dignity, on the one hand, and safety, on the other. An attempt to confront the problem is made in the benchmark ‘safety of clients with mental health needs’ (specifically, in terms of ‘balancing observation and privacy in a safe environment’). Yet, perhaps surprisingly, it is an earlier publication, Safety, privacy and dignity in mental health units: guidance on mixed sex accommodation for mental health services (NHS 2000), that provides a more detailed and honest appraisal of the relationship between privacy and safety; and it is one that matches this author’s experiences and observations during clinical placement at an EMI (Elderly Mental Illness) ward.

The ward in question, a mixed-sex ward with single sex corridors, conforms to the guidelines on privacy and safety outlined in the aforementioned NHS document. Consequently, while the single rooms on the ward ensure a degree of privacy, a ‘fail safe system for entry into rooms if staff are concerned about patients’ security’ is also in operation (NHS Executive 2000). Similarly, assessments of the patients’ susceptibility to self-harm (or suicide) are undertaken prior to the allocation of individual rooms; and the ward layout guarantees access to segregated toilet and bathroom facilities, without members of one sex having to pass through areas designated for the opposite sex.

In this author’s view, despite the conditions under which patients can be sectioned under the Mental Health Act (HMG 1983), and notwithstanding the way in which the above account of NHS policy and clinical practice highlights the manner in which patients are sometimes monitored in mental health facilities, there is no good reason to believe that principles of privacy and dignity are not generally adhered to. The point to emphasise is that, rather than being absolute, the principle of dignity is open to adaptation, especially where the issue of individual safety arises. Indeed, paradoxically perhaps, such modification may even provide a fuller scope to the exercise of dignity, because it is predicated on the well-being of the individual or individuals concerned.

To return to the Essence of Care guidelines, the document includes a range of other benchmarks and factors that relate closely, and appropriately, to privacy and dignity. Among these are: ‘assistance to eat and drink’ (‘food and nutrition’); ‘a physical and social environment conducive to continence and a healthy bladder and bowel’ (‘continence and bladder and bowel care’); and ‘environment within which oral and personal hygiene needs are met’ (‘personal and oral hygiene’). But it is the benchmark ‘communication between patients, carers and health care personnel’ – first included in the second edition of Essence of Care (DH 2003) – that is of particular relevance here, largely because much of it dovetails with an indispensable factor within the privacy and dignity benchmark: ‘privacy of patient-confidentiality of client information’.

With this in mind, this essay now turns to an opportunity this author had to reflect upon the implementation of confidentiality policy, at a local level, during time spent on a general adult nursing placement. Whilst on the ward in question, the policy document Information and Technology: Information Security and Confidentiality Policy (UHNS 2000) was made available to me. Emphasising the security of information in patient-care areas, the document stresses that the ‘[d]isclosure of patient-identifiable information [name, age, gender, address, patient’s diagnosis, current state of health etc.]… is a breach of confidentiality and can have serious consequences for the Trust’ (UHNS 2000). Notwithstanding the short duration of the placement, it was possible to evaluate routine practice on the ward against the recommendations of the policy. What was impressive was the continuity between the professional guidelines and the nature of nursing practice on the unit. Indeed great emphasis was placed on the fundamental importance of following the protocols laid out in official confidentiality policies.

The procedures pertaining to ‘telephone enquiries from patients’ relatives and friends (UHNS 2000)’ were among those singled out by the staff for consideration. The advice given was in accordance with the confidentiality directive, which states that ‘information should not be given unless the staff member is certain of the caller’s identity (UHNS 2000)’. Further attention was drawn to matters of confidentiality when staff nurses explained the importance of using password-protected electronic record-keeping in patient-care areas. They noted in particular that, when unattended, computer screens should be kept clear of sensitive information. Significantly, however, important qualifications were highlighted in relation to confidentiality, qualifications that are consistent with the BMA’s advice that, just as unrestricted access to patient-identifiable data by health professionals should be prevented, ‘[p]atients should be made aware that health teams need to share essential, relevant information in order to ensure that the safety and effectiveness of treatment are maximised’ (BMA 1999).

Despite research that has found standards in the NHS wanting (not least in relation to the privacy and dignity benchmark) experiences of clinical placements, so far, have given this author little cause to doubt the commitment of nursing professionals to matters of confidentiality in particular (Woogara 2004). Nonetheless, to enable a clearer understanding of the issues at stake in the discussion surrounding privacy and dignity it will be helpful to clarify some of the concepts underpinning (and the relationships between) both terms. As Woogara (2005: 34) observes, ‘the terms ‘privacy of the person’ and ‘dignity’ are interrelated’, in so far as dignity implies ‘respect for the person, privacy of the body, privacy of one’s space and territory, and having control and choice of one’s surroundings.’ Similarly, the multidimensional character of privacy (physical, psychological, social, informational) also implies (as does dignity) autonomy, or self-government (Scott et al. 2003; Burgoon 1982). And the desire to cultivate a climate of autonomous decision-making is of course especially pertinent to the modern healthcare environment, where the right to privacy is broadly recognised to be essential to maintaining patients’ independence (DH 2005).

Others, notably Wainwright (1995, cited in Scott et al. 2000), have sought to condense the idea ‘privacy’ into simply ‘two types’, one pertaining to personal information, the other to the physical aspect of the person. Meanwhile, Westin (1967: 31, cited in Woogara 2001) provides a more compelling, philosophical account of privacy, wherein he identifies (in advanced capitalist societies) four distinctive elements: solitude, intimacy, anonymity, reserve. Taken in turn, the composite aspects of Westin’s explanatory scheme make clear the importance of clarifying the meaning of privacy for the healthcare environment. Thus, ‘solitude’ implies a state in which an individual is separate and free from the observation of others. ‘Intimacy’ points to an individual’s facility to participate in family or friendship units. A third element, ‘anonymity’, arises when an individual is in a public place but wishes to be free from the scrutiny of others. Finally, ‘reserve’ describes an individual’s construction of ‘mental distance’ as part of ‘a psychological barrier against unwanted intrusions’ (Woogara 2001: 239).

If defining ‘privacy’ and its parameters has preoccupied the minds of many contributors to medical, nursing and healthcare journals, then establishing the salience and meaning of ‘dignity’ has proved to been an even more vexed question. In the first instance, however, it should be said that one need not agree with either Macklin’s claim that ‘dignity’ is so vague an idea as to be ‘useless’ or Beckworth’s assertion that dignity is a ‘right’ to recognise the significance of dignity, not least for nurses and their patients (Macklin 2003, cited in Gallagher 2004: 590; Beckworth 2006).

Bradshaw (2000) cites Stuart and Cuff’s Practical Nursing (1899) as an early example of a text emphasising ‘gentleness and dignity’ as an essential characteristic of nursing care. Similarly, at the Florence Nightingale commemoration service in May 2006, no less than the Archbishop of Canterbury reminded us that the founder of modern nursing viewed professionalism as ‘whatever served not only the physical health but the dignity of those being cared for’ (Beckworth 2006). It is clear, then, that dignity has long been deemed been a ‘core value’ for nursing practice. Nonetheless, despite the much-trumpeted claim that modern healthcare is moving away from medical paternalism towards to patient-centredness, dignity remains an under-defined concept in both nursing literature and Department of Health publications (Walsh and Kowanko 2002).

Haddock (1996, cited in Frankin et al. 2006) describes dignity as the quality of feeling valuable in relation to others, and being treated as such when that dignity is threatened. Elsewhere, Gallagher (2004) cites several attempts to define dignity. Mairis, for example, echoing Woogara (2005: 34), states: ‘Dignity exists when an individual is capable of exerting control over his or her behaviour, surroundings and the way in which he or she is treated by others’ (Mairis 1994, cited in Gallagher 2004: 589). No less useful is Shotton and Seedshouse’s ‘negative’ definition (1998, cited in Gallagher 2004: 589). Hence they suggest that ‘we lack [my emphasis] dignity when we find ourselves in inappropriate circumstances, when we are in situations when we feel foolish, incompetent, inadequate or unusually vulnerable.’ But perhaps the most important insight to be gained from the literature on dignity is that derived, in part, from Spiegelberg’s (1970) distinction between ‘intrinsic’ and ‘extrinsic’ dignity.

Dignity is the state or quality of being worthy of esteem and respect; and we earn or expect esteem and respect on the basis of common human values. Consequently, to treat a patient with dignity is to treat him or her with respect, and in the interests of his or her self-esteem. What Spiegelberg did was to distinguish between, on the one hand, our estimation of our own worth (intrinsic dignity) and, on the other, that conferred on us by others (extrinsic dignity). Therefore, where one is said to be able to have dignity, treat (or be treated) with dignity, or bestow dignity what is at stake is self-respect, in as much as valuing the dignity of others ‘requires an appraisal and recognition of one’s own value and worth, both as a human and as a professional’ (Gallagher 2004: 591). It is this acknowledgment of the two-fold character of dignity (respect for ourselves and others) that is conspicuous by its absence from both Department of Health literature and that of the Nursing and Midwifery Council (DH 2001b, 2003; NMC 2004).

As is consistent with reflective practice, where they are able to recognise the multi-faceted nature of privacy and dignity it should be incumbent upon student and registered nurses to adopt a properly critical perspective towards the health policies that they are expected to both implement and comply with. As part of a profession that is, in many respects, subordinate to government diktat, taking issue with, for example, some of the shortcomings of official guidelines is not a straightforward task for nurses to undertake. And yet, as this essay has sought to illustrate, ‘best practice’ will indeed be at its best when nurses set out to achieve it armed with the dignity and respect they owe to themselves and, above all, their patients.

References

Beckworth, S. (2006). Dignity is a core value. Practice Nursing. 17(6), 266

Bradshaw, A. (2000). Competence and British nursing: a view from history. Journal of Clinical Nursing. 9(3), 321-9

Burgoon, J. K. (1982). Privacy and communication. Communication Yearbook. 6, 206-249

Department of Health (2001). The NHS Plan: a plan for investment, a plan for reform. London: DH

Department of Health (2001b). Essence of Care: Patient-focused benchmarking for health care practitioners. London: DH

Department of Health (2003). Essence of Care: Patient-focused benchmarks for clinical governance. London: DH

Department of Health (2005). Independence, well-being and choice. London: DH

Department of Health (2006). A new ambition for old age: next steps in implementing the National Service Framework for Older People. London: DH

Franklin, L-L., Ternestedt, B-M and Nordenfelt, L. (2006). Views on dignity of elderly nursing home residents. Nursing Ethics. 13(2), 130-146

Gallagher, A. (2004). Dignity and respect for dignity – two key health professional values: implications for nursing practice. Nursing Ethics. 11(6), 587-99

Haddock, J. (1996). Towards further clarification of the concept ‘dignity’. Journal of Advanced Nursing. 5(24), 924-931

HM Government (1983). Mental Health Act. London: HMSO

Macklin, R. (2003). Dignity is a useless concept: it means no more than respect for persons or their autonomy. British Medical Journal. 327, 1419-1420

Magill-Cuerden, J. (2006). The curtain: for privacy or safety? British Journal of Midwifery. 14 (12), 723

Mairis, E. D. (1994). Concept clarification in professional practice: dignity. Journal of Advanced Nursing. 5(19), 947-953

Malcolm, H. A. (2005). Does privacy matter? Former patients discuss their perceptions of privacy in shared hospital rooms. Nursing Ethics. 12(2), 156-166

Manthey, M. (2001). Reflective Practice. Creative Nursing. 7(2), 3-4

NHS Executive (2000). Safety, privacy and dignity in mental health units: guidance on mixed sex accommodation for mental health services. London: NHS Executive

Nursing and Midwifery Council (2004). The NMC code of professional conduct: standards for conduct, performance and ethics. London: NMC

Scott, H. (1997). Can the NHS afford patient dignity and privacy? British Journal of Nursing. 6(3), 132

Scott, H. (2004). Should patient dignity prevail over nurses’ risk of injury? British Journal of Nursing. 13(8), 437

Scott, P.A., Välimäki, M., Leino-Kilpi et al. (2000). Autonomy and clinical practice 2: patient privacy and nursing practice. British Journal of Nursing. 9(9), 566-569

Scott, P.A., Välimäki, M., Leino-Kilpi et al. (2003). Autonomy, privacy and informed consent 1: concepts and definitions. British Journal of Nursing. 12(1), 43-47

Shepherd, E. (2006). Continence care must respect patients’ dignity. Nursing Times. 102 (47), 39

Spiegelberg, H. (1970). Human dignity: a challenge to contemporary philosophy. In: Gotesky, R. and Laszlo, E. (eds). Human dignity – this century and the next. New York: Gordon and Breach, 39-64

Taylor, J. (2007). Has dignity gone out of care? Nursing Times. 103(4), 18-20

University Hospital North Staffordshire (2000). Information and Technology: Information Security and Confidentiality Policy. UHNS

Walsh, K. and Kowanko, I. (2002). Nurses’ and patients’ perceptions of dignity. International Journal of Nursing Practice. 8(3), 143-151

Westin, A. F. (1967). Privacy and freedom. New York: Atheneum

White, C. (2006). Putting dignity at the heart of care. Nursing Times. 102(47), 8-9

Woogara, J. (2001). Human rights and patients’ privacy in UK hospitals. Nursing Ethics. 8(3), 234-246

Woogara, J. (2005). Patients’ rights to privacy and dignity in the NHS. Nursing Standard. 19(18), 33-37

Essays and Assignments from the Pen of a Student Psychiatric Nurse

“Individuals’ choices about how they live their lives make a major contribution to their own and in some cases other people’s health” (Ewles 2005).

Choose and alter an aspect of your behaviour that may help you to improve your present health status. Follow the assignment guidelines and also discuss how your behaviour change could in fact influence other people’s health.

This assignment will document and reflect upon my attempts to reduce the extent of my smoking habit, and will consider the relationship between my behaviour and the health of others, smokers and non-smokers alike. In addition to outlining the strategy adopted to effect changes in my behaviour I will also address, briefly, the political climate surrounding debates about passive smoking and the banning of smoking in public places (Forest 2004; Benison 2006; Bailey 2007; Percival 2007). My justification for introducing this second dimension to the assignment stems from a recognition of the newly significant (and, in my view, authoritarian) role that health policy has come to occupy in the government’s relationship with the public, as expressed in the concerted effort to transform popular attitudes towards health and personal responsibility (Fitzpatrick 1996, 1998, 2006).

Initially, my commitment to reducing the amount of cigarettes I smoke was less than total. This was certainly due, in part, to my stubborn aversion to the nature of government-backed anti-smoking campaigns, and to my opposition to the smoking ban in England (which came into force on 1st July). These are issues to which I will return later. At this stage, it is important to stress that, just as I regard as wrongheaded any claim for smoking as a uniquely ‘disobedient’ act, it is no less obvious to me that the decision to reduce or stop smoking is an unquestionably sensible one.

It is not necessary here to detail the key factors supporting the link between smoking and premature death from lung cancer. It is enough to say that this correlation was first established in 1954 by the epidemiologists Richard Doll and Austin Bradford Hill (Doll and Hill 1954; Doll et al. 2004). Of course, for smokers, the risk that their nicotine habit poses to their health is not usually the first thing on their mind each time they ‘light up’. I am no exception. Nonetheless, in identifying smoking as an aspect of my behaviour susceptible to modification I have surprised myself by the degree to which I have been forced to face up to the dangers of a routine practice that, previously, I had done little to alter.

I chose the first day of the smoking ban in England to be the first day of my endeavour to cut down on my smoking. I also opted to keep a video diary as a system of recording the progress of my behavioural change (and as a way of highlighting some of the critical observations raised in this assignment). From the very earliest stages of this project, notwithstanding my broader ‘political’ scepticism, I was also mindful of the importance of exploring theoretical perspectives on behavioural change, and of gauging how successfully they might be incorporated into my own strategy for change. To this end, I consulted Prochaska and DiClemente’s transtheoretical stages of change model (Prochaska and DiClemente 1982, 1983, 1984, 1986).

Prochaska and DiClemente’s psychological model of change identifies five stages of behavioural change: precontemplation, contemplation, preparation, action and maintenance. The essential components of the model provide a useful way of identifying the stage reached by an individual contemplating change, and helped to clarify some of my own feelings towards giving up smoking. Prochaska and DiClemente characterise ‘precontemplation’ as the prelude or precursor to change, during which time the subject is not seriously considering change, perhaps because he or she is unaware of (or uninformed about) the possible consequences of their habit, is unconvinced that the immediate advantages of behaviour change will outweigh the disadvantages, or, more plausibly, because he or she has become demoralised by failed attempts to change in the past.

Especially pertinent to my circumstances, however, is the subsequent ‘contemplation’ stage, the features of which underscore the situation in which I found myself at the onset of this assignment. Prochaska and DiClemente draw attention to the way in which this stage implies ambivalence towards change (1983, 1984). Strictly speaking, to be ‘ambivalent’ means to be torn equally between two opposite courses of action (in this case, continuing or discontinuing a smoking habit), but Prochaska and DiClemente’s model does allow for a more general emphasis on the various contradictory and conflicting attitudes towards the kind of alterations in behaviour that individuals have, by this stage, already come to recognise as desirable and/or necessary. Moreover, it quickly became apparent to me that that the key problem that the model as a whole identifies is also the one that I myself am most guilty of: procrastination.

These observations aside, I have been able to achieve some success in executing the third step in the change agenda: ‘preparation’. It can be gleaned from the literature on the subject that, while cutting down on smoking (my initial goal) should not readily be classed as an example of ‘action’ (the fourth stage in the model of change) it can nevertheless still be seen as a positive shift towards ‘more decisive action’ (Harvard Women’s Health Watch 2007; Zimmerman et al. 2000). My first achievement in this respect was, arguably, a symbolic one. Setting out to purchase forty cigarettes I made a conscious decision to buy twenty instead, with a view to testing my ability to manage a fifty per cent reduction in nicotine during an unchanged time period of three days.

After conducting a randomised population-based intervention study in Denmark Pisinger et al. (2005) noted that, because ‘there is no evidence that a ‘minimum 5 g’ [five cigarettes] reduction has any health benefit’, the decision was made to set ‘a ‘minimum 50%’ reduction’ over a six month period, in order to be able to measure any significant changes in health. With this is mind, while my symbolic gesture was certainly made in the spirit of ‘starting as I mean to go on’, I was all too aware that my early achievement was, in reality, a mere 20 g reduction in tobacco smoked over sixty hours. Nonetheless, my video diary does record some success in maintaining my commitment to reducing the number of cigarettes I would ordinarily smoke in work and domestic settings.

By the close of day one I estimated that I had smoked five fewer cigarettes than usual: where I would normally smoke between ten and fifteen cigarettes I managed to reduce that figure to seven. By the evening of day three my cigarette supplies were diminishing, not least because I had given away as many cigarettes as I had smoked. I chose not to buy any more that night. Day four, which involved a busy six-hour shift at my clinical placement (a private nursing home), did not afford me a great many opportunities to smoke. This explains, in part, the dramatic reduction in the amount of cigarettes I had smoked by three o’clock: one. Nevertheless, having turned down the offer of a cigarette break, and having been responsible for the hourly allocation of cigarettes to approximately ten clients, I did feel that my resisting temptation was a positive sign of things to come.

This self-confidence led me, with perhaps undue haste, to suspend my daily video diary entries for several weeks. Instead, I decided that reporting back after a month of ‘testing the waters’ would be, apropos Prochaska and DiClemente’s model of behavioural change, an appropriate way to comment on whether or not I had identified areas of ‘social support’, and to provide confirmation of my ‘underlying skills for behaviour change’ (Telford 2000; UCLA date unknown). However, before drawing any conclusions about my own progress I want to consider the question of not only how my behaviour might impact upon – or be interpreted by – others, but also the extent to which the moralisation and ‘politicisation’ of smoking dovetails with official medical opinion and advice.

Being a mental health student nurse, a smoker and the close friend of someone with severe mental health problems (and an excessive smoking habit) put me, potentially, in a position to bring some unique insights to this assignment. In so far as I succeeded in doing so, this was due largely to the relatively informal, filmed interview I conducted with the aforementioned friend (and which is included in my video diary).

Having spent considerable periods of his adult life as a patient in mental health institutions (as a consequence of being subject to bi-polar disorder) ‘Danny’ claims that smoking has given him a substantial degree of respite from depression and anxiety. Familiar with the fact that smoking is especially common among people with severe mental illnesses ‘Danny’ is also aware of the link between smoking, mental health and excess mortality (Glassman 1993; Brown et al. 2000, cited in Allen et al. 2004: 356). Despite this, he sees no prospect of moving past – to use Prochaska and DiClemente’s terminology – the ‘pre-contemplation stage’ of behaviour change. Discussing these matters further we could also foresee areas of both common interest and potential conflict.

Firstly, as a prospective nurse I am expected to place health promotion at the centre of my professional practice; and, as a smoker, modifying my behaviour is seen as a way to enhance my integrity as a care-giver and health advocate. In the relevant literature, varying degrees of emphasis have been placed on the effectiveness of smoking cessation services (Addington et al. 1998; Allen et al. 2004). Duncan (2006: 19) reminds us that, as part of the National Service Framework for Mental Health, ‘services in general practice should include advice to clients on changing life-style behaviours such as smoking, drinking alcohol and exercise’ – advice deemed applicable across all health specialties. Similarly, Furniss (2006) stresses the urgency of developing cessation programmes to tackle the huge health and social costs of smoking.

Secondly, when coupled with health promotion, the impact of my giving up smoking on other people’s health (specifically, mental health service users) can be looked at in two distinct ways. That is to say that, on the one hand, received wisdom would suggest that a non/ex-smoking nurse is in an ideal position to contribute positively to patient-centred anti-smoking health promotion and to enhance the general health of patients in his or her charge. On the other, research also indicates that a majority of mental health nurses are opposed to the proposed smoking ban in psychiatric units (July 2008), and to preventing staff from smoking with patients, on the grounds that it could have negative, anti-therapeutic consequences (Tarbuck 1996; Jochelson and Majrowski 2006).

In defending the second of these two perspectives it is tempting to counter those who argue that it is negligent to ‘pacify’ patients with cigarettes that they are ignoring ‘the soft messy ground of practice’ and the realities of mental illness (Lawn 2005; Manthey 2001: 5). Accordingly, my interviewee’s reaction to smoking cessation programmes was a sardonic one. Offer him a ‘bi-polar cessation programme’, he remarked, and he would sit up and take notice. Yet a re-evaluation of nurse-patient relations in mental health in particular is, arguably, also warranted on the basis that the alleged threat of ‘passive smoking’ has been wielded as much for moral and political reasons as it has for health and scientific ones.

It is ironic that Richard Doll, world-renowned epidemiologist and co-author of the first major study to make the link between smoking and lung cancer, should be a leading sceptic regarding evidence for passive smoking (Doll 1998; Fitzpatrick 2004; Lyons 2006). However, the spectre of second-hand smoke remains central to anti-smoking initiatives, as it does to the smoker’s consideration of the impact of his or her behaviour on the health of others. For writer and general practitioner Michael Fitzpatrick, this is an insidious trend borne of a social and political climate in which ‘the politics of behaviour’ has transformed health into a virtue, whereupon those who do not conform to, often questionable, health advice are effectively ‘in denial’ of the sins they are committing against themselves and others (Fitzpatrick 1998, 2004, 2006).

‘Once health is linked with virtue’, writes Fitzpatrick, ‘the regulation of lifestyle in the name of health becomes a mechanism for deterring vice and for disciplining society as a whole’ (1998). There is no doubt that this mood of critical scepticism has shaped my own outlook. Yet, notwithstanding the caveats, the virtue of Prochaska and DiClemente’s model – regardless of official policies on smoking and behaviour modification – is precisely that it stands on its own merits. It is for this reason that, despite having failed so far to progress towards the ‘action’ stage (wherein successful behaviour modification must be sustained for at least three months), I am confident that, rather than remain permanently ensconced in the ‘preparation’ stage, I will be able to overcome my smoking habit.

References

Addington, J., El-Guegaly, N., Campbell, W., Hodgins, D. and Addington, D. (1998). Smoking cessation treatment for patients with schizophrenia. American Journal of Psychiatry. 155(7), 974–976

Allen, D., Harvey, S., Marstin, P., Smith, S. and Wadhawa, S. (2004). Enduring mental illness and physical health care. Practice Nursing. 15(7), 356 - 360

Bailey, A. (2007). The ‘Big Ban’: a fresh start for smokers? British Journal of Nursing. 16(11), 641

Benison, L. (2006). English smoking ban. Practice Nursing. 17(3), 109

Brown, S., Inskip, H. and Barraclough, B. (2000). Causes of the excess mortality of schizophrenia. British Journal of Psychiatry. 177, 212–217

Doll, R. and Hill, A. B. (1954). The mortality of doctors in relation to their smoking habits: a preliminary report. British Medical Journal. 228, 1451-1455.

Doll, R. (1998). The first reports of smoking and lung cancer. In: Lock, S. et al. (eds.). Ashes to ashes: The history of smoking and health. Amsterdam: Rodopi, 130-140

Doll, R. et al. (2004). Mortality in relation to smoking: 50 years’ observations on male British doctors. British Medical Journal. 328, 1519-1533.

Duncan, D. (2006). Incentives for improving mental health care. Practice Nursing. 17(1), 18-21

Ewles, L., and Simnett, I. (1995). Promotion of Health: A Practical Guide. London: Balliere Tindall

Fitzpatrick, M. (1996). Warning: anti-tobacco crusades can damage your life. Living Marxism. 94, 16-18

Fitzpatrick, M. (1998). The tyranny of health [online]. Available from http://www.archive.org/web/web.php [Accessed 3 August 2007]

Fitzpatrick, M. (2004). We have ways of making you stop smoking [online]. Available from http://www.spiked-online.com/index.php?/site/article/1871/ [Accessed 9 August 2007]

Fitzpatrick, M. (2006). The stigma of smoking [online]. Available from http://www.spiked-online.com/Articles/0000000CAF8B.htm [Accessed 6 August 2007].

Forest (2004). Smoking in public places: an independent survey of public attitudes to smoking in pubs, bars and clubs. London: Forest

Furniss, L. (2006). Just nipping outside for a quick smoke. British Journal of Cardiac Nursing. 1(11), 508-509.

Glassman, A. H. (1993). Cigarette smoking: implications for psychiatric illness. American Journal of Psychiatry. 150, 546–53

Harvard Women’s Health Watch (2007). Why it’s hard to change unhealthy behavior – and why you should keep trying [online]. Available from http://www.health.harvard.edu/ [Accessed 5 August 2007].

Jenkins, I. (2007). Avoiding the burn of the smoking ban. Nursing & Residential Care. 9(8), 387-388

Jochelson, K. and Majrowski, B. (2006). Clearing the air: debating smoke-free policies in psychiatric units. London: King's Fund

Johnstone, J. R. (1991). Scientific fact or scientific self-delusion: passive smoking, exercise and the new puritanism. In: Peter Berger et al. Health, lifestyle and environment: countering the panic. London: Social Affairs Unit, 57-77

Lawn, L. (2005). Cigarette smoking in psychiatric settings: occupational health, safety, welfare and legal concerns. Australian and New Zealand Journal of Psychiatry. 39(10), 886-891.

Lyons, R. (2006). Smoking out the facts [online]. Available from http://www.spiked-online.com/index.php?/site/article/114/ [Accessed 12 August 2007]

Manthey, M. (2001). Reflective Practice in the UK. Creative Nursing. 7(2), 5-6

Moore, M. J. (2000). Passive smoking and health care: health perceptions myth vs. health care reality. Journal of Risk and Uncertainty. 21(2/3), 283-310.

Percival, J. (2007). Smoke-free legislation: time to have an impact. Practice Nursing. 18(7), 334-339.

Pisinger, C., Vestbo, J., Borch-Johnsen, K. and Jørgensen, T. (2005). Smoking reduction intervention in a large population-based study. The Inter99 study. Preventive Medicine. 40(1), 112-118

Prochaska, J. O. and DiClemente, C. C (1982). Transtheoretical therapy: toward a more integrative model of change. Psychotherapy: Theory, Research and Practice. 19(3), 276-288.

Prochaska, J. O. and DiClemente, C. C. (1983). Stages and processes of self-change of smoking: toward an integrative model of change. Journal of Consulting and Clinical Psychology. 51, 390-395.

Prochaska, J. O. and DiClemente, C. C. (1984). The Transtheoretical approach: Crossing traditional boundaries of therapy. Homewood, Ill., Dow Jones-Irwin.

Prochaska, J. O. and DiClemente, C. C. (1986). Towards a comprehensive model of change. In: Miller, J. W. and Heather, N. (eds.). Treating Addictive Behaviours: Process of Change. New York: Plenum, 3-27.

Roberts, J. (2002). NICE guidance on smoking cessation. Practice Nursing. 13(8), 346-349

Tarbuck, P. (1996). Smoking with patients: policy vs therapy. British Journal of Nursing. 5(4), 224 - 229

Telford, L. (2000). Why Should Health Promoters Be Theoretical? Ontario Health Promotion E-Bulletin [online]. Available from http://www.ohpe.ca/index.php [Accessed 1 August]

UCLA Center for Human Nutrition (date unknown). Prochaska and DiClemente’s Stages of Change Model [online]. Available from http://cellinteractive.com/ucla/ [Accessed 12 July 2007].

Zimmerman, G. L., Olsen, C. G. and Bosworth, M. F. (2000). A ‘stages of change’ approach to helping patients change behavior. American Family Physician. 61(5), 1409-1416 [online]. Available from: http://www.aafp.org/afp/20000301/1409.html [Accessed 5 August 2007].

Care co-ordination is a complex operation. With reference to relevant literature and legislation, discuss the process of co-ordinating care in your current placement area, and, using an example from this area, appraise the utility of this care package to that patient.

This essay will attempt to clarify the origins of the present system of ‘Care Co-ordination’ for mental health services, and examine some of the complexities in its development and application since its inception as the ‘Care Programme Approach’ (CPA) (DH 1990; 1999a). In addition, the role of care co-ordination in my current placement area (neuropsychiatry) will be considered through an evaluation of a specific care package, in terms of its efficacy in meeting both the principles set down by the Care Programme Approach and the needs of the client in question. In addition, in order to gain a fuller insight into current trends in care co-ordination the wider remit of the CPA/Care Co-ordination will be addressed, including some of the imperatives and principles underpinning its implementation.

Care Co-ordination and the CPA have their roots in the ‘care in the community’ policies of the 1980s and the shifting of service provision away from the older, long-stay mental hospitals towards community-based care (DHSS 1981; Parkinson 1981). And, for many, the following words from one of the key government policy documents of the time still ring true over a quarter of a century later: ‘Most people who need long-term care can and should be looked after in the community. That is what most of them want for themselves and what those responsible for their care believe to be best’ (DHSS 1981). Nevertheless, having long been linked (in the minds of the public and commentators alike) with the ‘abandonment’ of the seriously ill, as opposed to their care, the phrase ‘care in the community’, it is argued, has become ‘devalued’ (Dear and Wolch 1987; Court 1996: 532; Wheeler 2007). More recently, modified concepts, such as ‘spectrum of care’, have been put forward as alternative ways of characterising a mental healthcare system that is said to situate ‘the asylum at one end and the community at the other’ (DoH 1996; Carrier and Kendall 1998: 289).

The CPA was first proposed in the Conservative government’s 1989 White Paper, Caring for people, and was formally adopted and introduced in 1991, ‘to provide shape and coherence to what had often been haphazard, uncoordinated attempts to provide support in the community for people with severe mental illness’ (DH 1989; DH 1990; Simpson et al. 2003b: 490). Applicable to anyone aged 16 years or over in need of support from specialist psychiatric services (whether outpatient psychiatric services, in-patient psychiatric units or Community Mental Health Teams) the CPA also applies, in the case of the ‘Early Intervention Service’, to individuals below that age. Similarly, the elderly are entitled to treatment under the CPA, their needs determined through the Single Assessment Process (SAP) (DP NHS Trust 2006; MCIP 2006).

Notwithstanding the changes and modifications in the policies and practice of care co-ordination in the intervening years, the goal of effecting ‘systematic arrangements for assessing the health and social needs of people accepted into specialist mental health services’ remains unchanged (DH 1999a). As such, it is widely understood that the following, fundamental procedures are vital to the successful implementation of the CPA/Care Co-ordination: an assessment by a health and social care team, following referral to secondary, specialist psychiatric services; the development of a person-centred care plan, approved by a multi-professional team and (where appropriate and/or practicable) the client, advocate and informal carer; the allocation of a key worker/care co-ordinator to monitor the delivery of the care plan; and a regular review of the client’s care plan (DH 1990; 1999a; DCGN 2005).

In 1999, in accordance with the National Service Framework for Mental Health, the Department of Health acknowledged the need to update and streamline the existing model of care co-ordination for mental health service-users (DH 1999b). Setting out to transform the CPA into a ‘Whole Systems Approach’, the government sought to integrate the process with the screening and assessment procedures organised through Social Services ‘Care Management’. To signal this shift, the CPA would thereafter be referred to as ‘Care Co-ordination’ (DH 1999a, 1999b). The declared objective was the formation of ‘a unified health and social care assessment process’ and ‘a single care co-ordination approach for adults of working age with mental health problems’ (DH 1999a). In conjunction with the planned abolition of Supervision Registers (introduced in 1995 to address the problem of vulnerable patients ‘slipping through the net’ of psychiatric services), a rationalised, two-tier system of Care Co-ordination was introduced, built around ‘Standard’ and ‘Enhanced’ levels of care (DH 1999a).

In looking to refine the CPA, further provisions have also been put in place to ensure that a patient’s status under the Mental Health Act (MHA) be open to review at Care Co-ordination review meetings; and there has been a recognition of the need to monitor more closely the execution of the legal entitlement to after-care, as enshrined under Section 117 of the MHA (Wilkinson and Richards 1995; DH 2006). Arguably, however, the primary goal of Care Co-ordination continues to be that of bolstering the links between primary care, secondary care and the voluntary sector, on the basis that the synchronisation of care delivery is likely to be the most effective strategy for transforming the lives of people with mental illnesses (DH 1999a, 2001, 2002, 2006). With this in mind, and in order to test this claim, an example of Care Co-ordination implemented in my current placement area warrants consideration.

In 1998, the Health Advisory Service noted ‘the effectiveness of the complex care programmes (within the Care Programme Approach) that are being applied to patients with Huntington’s Disease when they are taken on by mental health services’ (SAC 1998). The Royal College of Psychiatrists has also endorsed the CPA/Care Co-ordination as good practice, not least in the neurobehavioural field (RCP 2004). The Department of Health and the NHS have continued to place great emphasis on the need for effective Care Co-ordination within neuropsychiatry. Moreover, this author’s experience provides strong evidence that the strategy can be put into practice with a high degree of efficiency and success (NHS 1997; DH 2005).

During my current clinical placement at a neuropsychiatric ward I observed and/or evaluated the assessments and multi-disciplinary output relating to a case of Care Co-ordination involving a 46 year-old patient with a history of depression, suicidal ideation, suicide attempts and self-harm. He was admitted to the ward in August 2007. Diagnosed with the genetic, degenerative brain condition Huntington’s disease in 2002, the patient was already known to neuropsychiatric services, having been admitted in 2004 following an overdose of sleeping tablets and attempted self-harm. (In the same year, as well as becoming divorced from his wife, the client was stabbed in the neck.) On this occasion, admitted as an informal patient for a 6 month mental health assessment, the client had presented with depression and suicidal ideation linked to loneliness and a stated inability to find a female partner.

After consulting the documentation relating to the patient’s Care Co-ordination it became clear that ward-based care planning, assessments and other nursing documentation represent a crucial aspect of the recovery-based, client-centred philosophy underpinning the CPA – whether applied within or without the hospital setting (Berger 2006). In this case, plans addressing ‘unmet needs’, ‘relapse prevention’ and ‘crisis intervention’ were drawn up. It is true that care plans can sometimes be perfunctory, with minimal consideration given to understanding wider social circumstances. What is more, limited time and resources can see care reduced to symptom management, treatment plans and compliance with medication. Yet the nursing process (assessment, planning, implementation, evaluation), of which it has been said (in its application to care planning) is ‘arguably the most important part of nursing care’, can still prove to be, as it did in this case, a key factor in the successful management of a patient’s needs (Wright 2005: 71).

In the first instance, risk assessments on admission to the ward formed an important part of the process of establishing the appropriate level of care provided for by the system of Care Co-ordination. After an initial assessment, a battery of detailed risk assessments was carried out, pertaining not only to the patient’s mental health, but their physical well-being aswell (e.g. the WHAMM Falls Risk Assessment). Of those assessments relating directly to mental state, a series of related risk factors were ‘scored’ according to their actual or potential applicability to the patient. Included within this standardised Care Co-ordination Risk Assessment documentation are: exploitation and harm by and/or to others; severe self-neglect; suicide; and deliberate self-harm. A further ‘Modular’ risk assessment evaluates the patient’s history against imminent and future potential for harm, in relation to, among others: overdose; self-mutilation; disability; chronic pain; feelings of hopelessness/lack of self-worth; relationship breakdown; impaired motivation and/or social functioning; and social isolation.

It should be stressed that this cursory summary of risk assessments need not imply that they have a merely quantitative character. On the contrary, while striving to be as objective as is possible, they are the building blocks of a qualitative, person-centred structure of care provision. To that end, the thorough, methodical nature of the initial, assessment-based stages of Care Co-ordination, in this instance at least, lent itself well to the Whole Systems Approach suggested by Care Co-ordination. And it is for this reason that they helped to facilitate relevant contributions and effective interventions from the multi-disciplinary team assigned to the patient’s clinical and social care.

The multi-professional entries in the aforementioned client’s notes drew on and complimented the knowledge already gained from his initial assessments. Alongside the consultant psychiatrist and the care co-ordinator (a senior nurse), the care team assembled for the patient’s Care Co-ordination included: a social worker; an occupational therapist; a speech and language therapist; a physiotherapist; an advocacy worker; the patient’s brother; and the patient/client/service user himself. The role of the care co-ordinator (who, prior to the modifications in the delivery of the CPA, was called the ‘keyworker) is to assume overall responsibility for the co-ordination of the care team, which includes making sure that the actions proposed in the client’s care plan are carried out, and that regular care plan reviews are arranged (DCGN 2005). Out of this multi-agency approach to evaluating the needs of the patient, ‘comprehensive assessments’ were produced by the professionals involved, all of which were returned to the service user’s social worker, and then transferred to the multi-professional documentation. The significance of assimilating the results of these investigations cannot be underestimated. For instance, the speech and language therapist’s report addressed factors such as oro-motor skills, expression, comprehension, reading comprehension and swallowing. Where a patient has a dual diagnosis of Huntington’s Disease and depression, the information derived from such an investigation can be of critical importance in gauging the impact that impairment in both communication and self-care skills can have on mental health (Guyon 2007; Zrínyi and Zékányné 2007).

Similarly, the ‘home assessment’ conducted by the occupational therapist, and observed by both myself and the patient’s social worker, proved to be decisive in determining the direction the Care Co-ordination was to take. To clarify, despite the patient’s wish to return home, grave concerns were raised about the risks posed by the combination of his unwillingness to confront the negative impact that Huntington’s Disease would have on the completion of everyday tasks and the damaging consequences that social isolation in his home environment could have on both his physical and mental health. The first Enhanced Care Co-ordination Review meeting, held a month after the patient’s admission, drew further attention to these problems, and yet, despite the misgivings aired by both his brother and the professionals present, the client persisted in his desire to return home.

As a result of the Care Co-ordination Review, two referrals were made. The first was to a Mental Capacity Advocate, with whom the social worker concurred that the client had the capacity to make the decision in question (MCIP 2006; Ross 2007). The second referral, made by myself, was to ASIST (Advocacy Services in Staffordshire), on the grounds that the service user may need the support and advice of a voluntary advocate, in order to address the possible options open to him, independent of (but with reference to) medical and legal imperatives. During this time, there was a marked decline in the client’s physical and mental health, which was instigated, in part, by his refusal to comply with medication (in protest at the decision made in the wake of his home assessment). This gave rise to complications, such as an intensification of the patient’s chorea, and further manifested itself in the form of an acutely aggravated and aggressive state.

The issue of the client’s discharge options remained a priority at subsequent ward rounds and Care Co-ordination Review meetings. In due course, perseverance and professional commitment reaped rewards for all concerned. The patient was persuaded of the seriousness of the situation and, paying close attention to the need for a client-centred approach to clinical and social care, he was asked to consider the possibility of moving to a nursing home, where care appropriate to his complex needs could be provided. As I write, the client is considering a range of options in this regard and, in recovering some of the pride and dignity he felt he had lost, is experiencing a marked improvement in his mental health.

Despite this very positive appraisal of Care Co-ordination in action, discussions (both formal and informal) centred around the CPA/Care Co-ordination are sometimes characterised by a narrowly instrumental focus on discharge and after-care, as opposed to a broader emphasis on the extensive view of care implied by a Whole Systems Approach. Undoubtedly, admission to hospital can sometimes run the risk of Care Co-ordination being suspended and continuity of care being interrupted. The Department of Health consultation document Reviewing the Care Programme Approach states: ‘The fact that a service user needs additional support in an in-patient or residential setting should prove no barrier to continuity of care planning.’ It continues: ‘For those on the CPA the responsibilities of the care co-ordinator will continue. For people not already on the CPA, a care co-ordinator should be appointed well in advance of discharge and arrangements made clear about future contact, risk and safety management and home care arrangements’ (DH 2006). In other words, accepting that the principal dynamic at work should be preparing the patient for his or her return home, admission to a psychiatric unit should, in itself, prompt the implementation of Care-Co-ordination.

This essay has not addressed the many, often stinging, criticisms of the CPA/Care Co-ordination. Yet one notable feature of much of the literature questioning the success of Care Co-ordination is that, in addressing the confusion, frustration and conflict surrounding the utility, or otherwise, of the approach, critics tend to focus more on the manner in which it has been implemented than on the content of the policy itself, a criticism which, unsurprisingly, its defenders are happy to concede (Sullivan 1997; Simpson et al. 2003, 2003b; Kingdon and Amanullah 2005). For this author, while this essay does not afford the scope to examine political questions too closely, there are certainly features of government policy that play a largely negative role in a whole host of health initiatives, not least the social engineering that, in my view, lies behind many of the government’s claims for ‘empowerment’ and ‘social inclusion’. Notwithstanding these reservations, however, and as the case study in this essay has made clear, whether because of or despite the manner of its implementation the health and social care professionals who are managing the care of the service-user in question have drawn out the most positive aspects of the present system of Care Co-ordination and put them into practice in such a way that the value of the client’s care package was never in doubt.

References

Berger, J. L. (2006). Incorporation of the tidal model into the interdisciplinary plan of care – a program quality improvement project. Journal of Psychiatric and Mental Health Nursing. 13, 464-467

Carrier, J. and Kendall, I. (1998). Health And The National Health Service. London: Athlone Press

Court, C. (1996). Government admits mental health service problems. British Medical Journal. 312, 531-532

Dear, M. and Wolch, J. (1987). Landscapes of despair: from deinstitutionalization to homelessness. Oxford: Polity

Department of Health and Social Security (1981). Care in the community: a consultative document on moving resources for care in England. London: HMSO

Department of Health (1989). Caring for people: community care in the next decade and beyond. London: HMSO

Department of Health (1990). The Care Programme Approach for people with a mental illness referred to the specialist psychiatric services. London: HMSO

Department of Health (1995). Building bridges: a guide to arrangements for inter-agency working for the care and protection of severely mentally ill people. London: HMSO

Department of Health (1996). The spectrum of care: local services for people with mental health problems. London: HMSO

Department of Health (1999a). Effective care co-ordination in mental health services: modernising the Care Programme Approach. London: HMSO

Department of Health (1999b). A National Service Framework for mental health: modern standards and service models for mental health. London: HMSO.

Department of Health (2001). The journey to recovery: the government’s

vision for mental health care. London: HMSO

Department of Health (2002). Community mental health teams: mental health policy implementation guide. London: HMSO

Department of Health (2005). Independence, well-being and choice: our vision for the future of social care for adults in England. London: HMSO

Devon Partnership NHS Trust (2006). Care programme approach operational policy. Devon: DP NHS Trust

Directorate of Clinical Governance and Nursing/North Staffordshire Combined Healthcare NHS Trust (DCGN) (2005). How can we help you? Information about Care Co-ordination for service users and their carers. Stoke-on-Trent: Combined Healthcare NHS Trust

Guyon, A. (2007). Assessments: speech and language therapy. Nursing & Residential Care. 9(10), 486-489

Kingdon, D. and Amanullah, S. (2005). Care programme approach: relapsing or recovering? Advances in Psychiatric Treatment. 11 [online]. Available from: http://apt.rcpsych.org/ [Accessed 10 December 2007]

Mental Capacity Implementation Programme (MCIP) (2006). Making decisions: a guide for people who work in health and social care. London: MCIP

NHS Health Advisory Service - Mental Health Services (1997). Heading for better care: commissioning and providing mental health services for people with Huntington’s disease, acquired brain injury and early onset dementia. London: NHS

Health Advisory Service

Parkinson, C. (1981). The right approach to mental health: a report based on the work of a Conservative policy group. London: Conservative Political Centre

Ross, C. (2007). The Mental Capacity Act: an overview. Nursing & Residential Care. 9(12), 556-561

Royal College of Psychiatrists (2004). Good Psychiatric Practice (2nd edn.). London: RCP

Scottish Affairs Committee (1998). Memorandum submitted by Scottish Huntington’s Association: Appendix 2 – Key issues relating to Huntington’s disease adapted from the HAS report. London: HMSO

Simpson, A., Miller, C. and Bowers, L. (2003). Case management models and the care programme approach: how to make the CPA effective and credible. Journal of Psychiatric and Mental Health Nursing. 10(4), 472-483

Simpson, A., Miller, C. and Bowers, L. (2003b). The history of the Care Programme Approach in England: Where did it go wrong? Journal of Mental Health. 12(5), 489-504

Sullivan, P. (1997). The care programme approach: a nursing perspective. British Journal of Nursing. 6(4), 208-214

Wheeler, M. (2007). Interview with Maggie Wheeler (chair of the Norfolk And Waveney Mental Health Trust) at BBC Norfollk [online]. Available from: http://www.bbc.co.uk/norfolk/ [Accessed 2 January 2008]

Wilkinson, E. and Richards, H. (1995). Aftercare under the 1983 Mental Health Act. Psychiatric Bulletin. 19, 158-60

Wright, K. (2005). Care planning: an easy guide for nurses. Nursing & Residential Care. 7(2), 71-73

Zrínyi, M. and Zékányné, R. I. (2007). Does self-care agency change between hospital admission and discharge? An Orem-based investigation. International Nursing Review. 54(3), 256-262

Define and explore how reflection can influence learning in clinical practice. Within this assignment, include reflection on your recent clinical experiences during Module 1, and recognise situations where you acknowledged the limitations of your own abilities and therefore required referral to a registered practitioner.

In this essay, I will examine some of the principal issues arising from the relationship between nursing and reflective practice, and, by drawing on my own experiences, I will further consider the extent to which theoretical models of reflection capture and compliment the essence of work-based learning.

Before setting out to demonstrate how reflection can play a key role in clinical practice I will first of all endeavour to outline the theoretical parameters of reflection itself. In recent years, reflective approaches to nursing, in the United Kingdom in particular, have evolved to support the broader goal of ensuring greater dynamism and effectiveness within the nursing profession (Manthey 2001; Sills and Tate 2004). It is against this background that a range of theoretical models of reflection have been applied, the hypotheses of which demand closer attention.

Of the various, more or less comparable, reflective models applied to work-based learning I will focus here on the approaches, or those aspects of them, that are especially pertinent to the early stages of training to be a mental health nurse. In the first instance, perhaps because of its simplicity and ‘user-friendliness’, the Gibbs Reflective Cycle (Gibbs 1988) is often highlighted as being especially useful to first-year student nurses faced with the prospect of engaging in critical reflection and reflective practice, often for the first time. For the same reason, it can be shown to be of general relevance to student nurses, irrespective of branch specialism.

The popularity of the Gibbs Reflective Cycle derives from its universal applicability, and for students evaluating their clinical practice and assessing the quality of their work-based learning it provides the most straightforward model for structured reflection. Firstly, it advocates that the student begins with a simple description of events. This should be followed by: an account of his/her feelings; an evaluation of the benefits and shortcomings of the experience; a broader analysis of the numerous situations, staff and patients constituting that experience; a conclusion drawn from insights gained from the previous stages in the cycle (including a retrospective critique of the student’s actions); and an action plan detailing how the student would anticipate confronting a similar situation in future.

Corresponding to the six stages in the Gibbs cycle (Description, Feelings, Evaluation, Analysis, Conclusion, Action Plan) are six exploratory questions: ‘What happened?’; ‘What were you thinking and feeling?’; ‘What was good and bad about the experience?’; ‘What sense can you make of the situation?’; ‘What else could you have done?’; ‘If it arose again, what would you do?’. A cursory glance at other models of reflection suggests that, rather than providing full-blown alternatives to Gibbs, they merely place differing degrees of emphasis on the same themes. At one level of course, this is clearly the case, as they all share the goal of identifying the most effective route to establishing a practicable approach to reflective practice.

Nonetheless, it is important to recognise the often subtle differences distinguishing one theoretical model from another, not least because this will help to clarify the strengths and weaknesses of many of the ideas underpinning reflective models per se.

Schön’s theory of reflection-in-action (1983, 1987) is a case in point. Schön has been described as a pivotal figure in the development of reflective practice, ‘on the high, hard ground of certainty in the academic ivory tower and the soft messy ground of practice’ (Vaughan, cited in Manthey 2001b: 5). A tripartite model, Schön’s theory of reflection is built around the inter-related concepts of ‘knowing-in-action’, ‘reflection-in-action’ and ‘reflection-on-action’. Thus, as Schön (1987: 29) contends, ‘In reflection-in-action, the rethinking of some part of our knowing-in-action leads to on-the-spot experiment and further thinking that affects what we do – in the situation at hand and perhaps also in others we shall see as similar to it.’ This configuration implies a transformative process, whereby reflective learning moves from the intuitive, familiar ‘know-how’ we apply to everyday working practices, through the ‘thinking on our feet’ associated with the improvised experiments we apply to unexpected workplace demands, to the intellectual deliberation we must engage in to facilitate a proper understanding (and if necessary, a refinement) of our ways of working.

Again, on first reading, Schön’s reading of the fundamentals of reflection appears to be similar, in essence, to Gibbs’. But if Schön’s approach to perfecting our understanding of reflection is examined in relation to further attempts to do the same we will be better placed to identify what are, arguably, qualitative differences between the philosophical assumptions underpinning, ostensibly, comparable theories of reflection. In this respect, Johns (2000) and Rolfe (2001) provide us with the opportunity to consider if the claims so often made for the advantages of ‘reflection‘ sometimes disguise the sort of introspection that is not necessarily beneficial to a professional environment (Kim 1999).

Like Schön, Johns’ interpretation of the role of reflection allows for a more complex, less reductive method than Gibbs. Where the Gibbs Reflective Cycle, in quantitative fashion, asks, ‘What needs to be added? What needs to be taken away?’, Johns’ Model of Structured Reflection invites the student to ask what he or she brought to the decision-making process in the first place. This question of influencing factors is a crucial one. Once the role of internalised and externalised ethics within reflection is acknowledged, the possibility of a more effective resolution of the challenges posed by professional practice suggests itself. Rolfe (2001), too, appreciates that the knowledge, assumptions and broader dynamics of reflection cannot be reduced to ‘learning from our mistakes’, and recognises that a synthesis of the subjective and the objective is required if reflection is to be anything more than the exploration of our innermost feelings.

While any formal, ‘technical’ model of reflection is bound to reveal its shortcomings when tested against the unpredictability of professional practice this need not imply that models of reflection cannot be used as general guides to action. Nevertheless, it is important to take on board the fact that it is not enough for ‘theory’ to merely describe and prescribe. Certainly, the role of theory is, in part, to logically reconstruct ‘reality’, but it must more do more than that – it must assimilate our experience of that reality, in order for us to be able to act on and shape our (working) environment with rigorous intent. If our subjective actions are rooted, simultaneously, in our working environment and the preconceptions we bring to that environment, then resolving the problems that confront us must surely demand of us a collective response.

For structured reflection to be effective it should be corroborated. Student nurses, for example, do not only need forums to exchange views, but also ample opportunities to support the development of a framework for establishing exactly what kind of framework for reflection they need. Rather than relying solely on ‘ready-made’ models of reflection the trainees’ commitment to mastering a professional approach to their work requires that they base their intellectual contemplation firmly in the concrete reality of their respective clinical environments (Kolb 1984). Without such a meeting of minds, mere introspection and abstract speculation could become the student nurses’ modus operandi.

Having considered, in some detail, the theoretical foundations of reflective practice I want to now to consider how my own experience on placement, in a Mental Health Resource Centre, has both inspired my thoughts on reflection and forced me to recognise the ‘mismatch’ between my stance on reflective practice and the reality of being a relatively inexperienced student nurse.

Prior to starting my training, I spent eight months working as a volunteer with the mental health charity MIND. Consequently, I began my first placement with the kind of knowledge, insights and skills that I was encouraged to believe were applicable to the role of a mental health nurse. And yet, since the beginning of my training, because my personal and professional development have been focused around adapting to the needs and demands of working with a multi-disciplinary team in a Combined Healthcare setting, my reflection has centred, initially, on the ways in which I tested my knowledge against the demands of working with nurses, social workers, occupational therapists and a mental health client base under the auspices of the NHS.

While matters such as promoting the dignity and interests of people of mental illnesses, recognising the wide range of social issues associated with mental illness, and understanding the importance of maintaining personal and professional boundaries are facets of my voluntary work that I confidently brought to bear on my placement experience, the ‘neutrality’ of voluntary work did not prepare me for the unique requirements of mental health nursing (Mid-Staffs Mind [date unknown]). That is to say, just as mental health charities are an important point of contact both for people with mental illnesses and overstretched statutory services, they are rarely equipped with the resources or the professional staff to fully address the short and long-term needs of people with serious mental illnesses. As such, the responsibilities I have begun to become acquainted with since working alongside qualified mental health nurses have further encouraged me to look more closely at the, sometimes fraught, relationship between the therapeutic and clinical aspects of psychiatric nursing.

While I would not want to question the efficacy of charitable organisations that often afford clients an enviable amount of therapeutic support, the principles of continuity of care are, as far as my experience tells me, implemented most effectively via qualified nursing professionals. Moreover, it is the question of record keeping in particular that, for my part, illustrates both the significance of upholding a duty of care to patients/clients and my own reflections on the limitations of my abilities at this early stage in my training.

Although not a requirement when working as a volunteer with Mind (as professional responsibilities were minimal), maintaining accurate and legible records is an essential and integral part of nursing practice, and I was made aware at an early stage during my clinical placement of the vital function that record-keeping plays in ensuring continuity of care. While on placement, in conjunction with completing admission procedures, and assisting with a range of assessments (Physical, Kitchen Risk, 3-Point Risk Assessment etc.), I was able to carry out other procedures essential to nursing, including: taking and recording blood pressure; measurement of body temperature; identifying nutritional needs; and administering medicine by intramuscular injection. And yet, as I have already intimated, record-keeping is perhaps the most appropriate focus for the purposes of this essay, because, concurrent with my reflections on the contrasts between professional and voluntary caring environments, it was this feature of clinical practice that led me to seek professional advice from registered practitioners.

Whereas working as a volunteer for Mind did not require record-keeping as a matter of course, on placement entries in patients’ notes were expected to be made whenever observations of changes in patients’ mood or behaviour, mental or physical health were deemed significant enough in themselves to be recorded. Furthermore, the significance of such changes was always to be judged on the basis of their bearing on holistic care plans. It was in this context that I sought clarification of clinical protocols, concerned as I was to keep accurate – and therefore, effective – records. The more sure I became of the relevant procedures in this regard the more proactive I became in taking responsibility for them, which, in practice, meant making entries in records whenever I considered it to be appropriate.

It is perhaps ironic that, despite the reservations I have expressed about the utility of oversimplified and reductive approaches to reflection (and my claim that reflection can only be truly effective if it is executed collectively), I should choose to close this essay by defending the Gibbs Reflective Cycle. Yet it is because of my limited experience at this point in the course that I am in a position to reflect soberly on the efficacy of attempting, at this point in time, to put into practice more ambitious modes of reflection. I do not believe there is any contradiction at work here. Instead, I have come to recognise that my limitations are due less to a lack of confidence about being able to fulfil the nursing role than an unreasonable expectation that this is possible at such an early stage in my training. In this respect, Gibbs’ question, ‘If [the situation] arose again, what would you do?’, is not a retreat from my argument that a more dynamic, collective approach to reflection is needed. Rather it is the first step towards critical reflection-on-action.

References

Gibbs, G. (1988) Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Further Education Unit, Oxford Brookes University

Grech, E. (2004) Hegel’s Dialectic and Reflective Practice – A Short Essay. International Journal of Psychosocial Rehabilitation. 8, 71-73

Johns, C. (2000) Becoming a Reflective Practitioner: A Reflective and Holistic Approach to Clinical Nursing. Practice Development and Clinical Supervision. Oxford: Blackwell

Johns, C. (2002) Guided Reflection: Advancing Practice. Oxford: Blackwell

Kim, H. S. (1999) Critical Reflective Enquiry for Knowledge Development in Nursing Practice. Journal of Advanced Nursing. 29, 5, 1205-1212

Kolb, D. A. (1984) Experiential Learning: Experience as the Source of Learning and Development. New Jersey: Prentice Hall

Manthey, M. (2001) Reflective Practice. Creative Nursing. 7, 2, 3-4

Manthey, M. (2001b) Reflective Practice in the UK. Creative Nursing. 7, 2, 5-6

Mid-Staffs Mind (date unknown) Volunteer Handbook and Personal Record

Rolfe G., et al. (2001) Critical Reflection in Nursing and the Helping Professions: A User’s Guide. Basingstoke: Palgrave Macmillan

Schön, D. A. (1983) The Reflective Practitioner: How Professionals Think in Action. London: Temple Smith

Schön, D. A. (1987) Educating the Reflective Practitioner: Toward a New Design for Teaching and. Learning In the Professions. San Francisco: Jossey-Bass

Sills M. and Tate S. eds. (2004) The Development of Critical Reflection in the Health Professions. Learning and Teaching Support Network/Centre for Health Sciences and Practice Occasional Paper, 4