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