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Community Health Nursing

VII. Conceptual Approaches to Care

INTRODUCTION

            The term ‘nursing model’ was probably introduced to you in your basic education, and used for assignment work. Nursing models are supposed to be used in practice but in reality they are generally not used well, and appear to serve more as checklists for care plans rather than to inform the direction of nursing care. You may now be questioning the value of models of nursing, if they are simply used as a theoretical exercise in nurse education and a checklist in routine practice, but nursing models can, properly used, facilitate thinking about care and the philosophy that underpins it.

            Most nurses have used one or more nursing models. You are likely to be familiar with the Activities of Living model (Roper, Logan and Tierney 1980, 2000) and the Self Care model (Orem 1971, 1991). There are many models that can inform nursing and health practice. Models are not simple; they have been very rigorously contemplated by experts and each one serves as a representation of nursing. An interesting point about nursing models is the way in which they vary quite considerably, so that the purpose and intention of one, and the way in which it informs nursing, is quite different from these aspects in another model, and each is helpful to different branches of nursing.This will be discussed as the chapter develops.

PHILOSOPHIES OF CARE

           It is unlikely that anyone has a blank sheet, mentally, when approaching patient care, and this indicates that professionals take a considered approach in this matter. There are several labels for these general approaches. One approach to nursing is known as task-orientated – referring to the clinical task being carried out in isolation from any other aspects that influence the patient’s condition. Thus the nurse dresses the wound and does not consider other factors that could influence the healing of the wound or the patient’s comfort. Most nurses have heard the term biomedical model, which refers to treating the medical condition of the patient in isolation from the patient as a person. For instance, the patient’s heart condition would be treated but their excess weight and sedentary lifestyle, and the anxiety they might have about their health, would be ignored. Pearson et al. (1996) consider that many nurses still use the biomedical model as the basis for their practice.

            A term that is often used in relation to a general philosophy of care is holistic. The holistic approach takes into account a range of physiological and personal considerations for each individual and also places them in the context of contemporary society and of current health care provision. Holism is concerned with balance, i.e. with balancing the physical, psychosocial, and economic relationships of the person, with the environment in which they live (Aggleton and Chalmers 2000). Some branches of nursing, for example the nursing of those with learning disabilities, are more likely to take a holistic approach, as clients are not perceived in terms of a medical condition.

          The underlying philosophy of our approach to nursing very much reflects our individuality. ‘Philosophy’ refers to the beliefs and values that shape the way each of us thinks and acts. You will certainly have heard the word used in the context of philosophy to life. Some common sayings exemplify such philosophies: Live now pay later; A short life but a good one; You reap what you sow. These sayings demonstrate our use of the term philosophy in this context: how our beliefs and values shape thinking and influence actions. It is to be expected that life experiences, education, professional  socialisation  and professional experience will shape a nurse’s philosophy of care. Thus our underlying philosophy of care says something about us as individuals with unique personal experience.

CONCEPTUAL MODELS

           Nurse theorists have examined the concept of nursing and have illustrated their ideas through nursing models. The full term is ‘conceptual model’, differentiating this kind of model from the sort that are exact miniatures of real objects – model cars, boats, buildings, for example. Each of these can be perfectly recreated as a working model. Is it possible to build such a model of nursing? The answer is, of course, No; and the reason for this is that nursing is a concept. A concept is a collection of images and ideas that help to classify things and it is not possible to build anything material from images and ideas. The notion of a concept can be explained through something that is familiar, for example the concept of spring. There are certain aspects that embody spring: lambs, daffodils, buds on trees, sunshine and warmer days. Put all these together and a set of images that creates a picture of the season of spring comes to mind. Nursing is a concept that is built around a set of images.

          Your concept may involve images about caring, knowledge about health and illness, prevention of ill  health, rehabilitation and enabling people to help themselves, partnerships with patients and other health workers, the list goes on. When nursing is viewed in this way it is easy to determine why models of nursing are conceptual. It would be impossible to build such a set of images into a visible working model.

       It is possible to see that models may differ quite considerably because nurses think differently and hold divergent views about the concept. The difference in views will also reflect the varied concepts that are embodied in the different specialities of nursing. Take, for example, the conceptual difference between mental health and acute nursing. The concepts that make up the two roles will vary because the nature of nursing is different in each role; mental health nursing treating psychological disorders and imbalances while acute nursing is concerned with physical illness or disability. As conceptual models are developed for the nursing role it is logical that they will differ in accordance with the differences between branches of nursing.

         Fawcett (1984) identified some common ground by analysing four key concepts that are embodied in all nursing models. These are: (1) the person or individual; (2) the environment in which nursing takes place; (3) health; and (4) nursing itself. Whatever other concepts make up a particular model, these four are found in all. Nurse theorists have attempted to build conceptual models that illustrate ‘systematically constructed, scientifically based, and logically related sets of concepts which identify the essential components of nursing practice’ (Riehl and Roy 1980: p. 6).

Building Nursing Models

         Models must be put down in writing/text to enable them to be shared and used by other nurses. It is in this state that you have probably encountered nursing models. You might imagine how difficult it is to represent a complex set of concepts in writing. All models require to be portrayed through the written word and with the use of diagrams.

        Before any model can be effectively used it must be interpreted and understood. It may take time to work through some of the terminology, but this is necessary if the is model to be used as intended. You can see that Orem’s model (1980) is based on the ability of people to care for themselves. The model represents a balance between what people need to be able to do, which Orem refers to as ‘universal self care needs’ and a person’s ability to perform their care, which Orem refers to as ‘self care’. The model also lists areas where, for various reasons, an individual may require nursing intervention and suggests, under methods of helping, the form that such intervention might take.

       The model proposed by Orem has several components that relate to self care, starting with the premise that individuals wish to be independent and listing areas where people normally meet their own self care needs. There are health-related reasons that interfere with people’s ability to be independent and to care for themselves. The model looks at general reasons why a person may need help and makes suggestions about ways in which a nurse may support a patient in their striving for self care. The overall philosophy is to support self care and independence, and this sets the tone of this particular model and the direction that nursing care will take.

       Representing this conceptual model is not easy and Orem supports the concepts embodied in the model with detailed explanatory text. To use any model well, the whole model should be applied, with all concepts captured, in its application to patient care. Nurses tend to take what they consider to be the useful ideas from models and apply them in isolation. A prime example of this is the use of the Activities of Living model (Roper, Logan and Tierney, 1980, 2000), where the list of daily living activities is used as a checklist against which care plans are developed. This action ignores the essence of the model.

       You should now have an understanding of the nature and purpose of a nursing model. One or more models should be used by a care team to guide the process of care, and the model(s) must be supported by all members. The team leader has responsibility to ensure that all team members are sufficiently knowledgeable to be able to use the chosen model(s) competently to follow through the planned programme of care. Effective caring using a nursing model is a team effort.

Models with Differing Philosophies

         You may not feel that a Self Care model is suitable for the patient that you have in mind or for your branch of nursing. There are other options to explore, some similar to the ideas expressed in Orem’s model, others very different. A similar model was developed by Roper, Logan and Tierney (1980, 2000), informed by earlier work from Henderson, who offered a definition of nursing based on 14 activities of daily living (Henderson 1966). The Activities of Living model is well known and much used in the British Isles. It approaches nursing care by considering the activities of living that are common to all people, and how these can be influenced by a range of factors, the origins of which might be physical, psychological, social, cultural, environmental, political or economic. Other aspects that come into the model are the age of the person and the degree to which they are able to lead an independent life. The model focuses strongly on the many factors that influence activities of daily living and requires nurses to take these into consideration in making judgements about nursing care.

          Self care and activities of living tend to be concerned with planning nursing care in order to meet physical health deficits, which is why these two models are widely used to nurse patients with acute and chronic illnesses. They are equally suitable for wider use. Aggleton and Chalmers (2000) illustrate this point by applying the Activities of Living model to bereavement.

        Other models take a very different philosophical approach. Roy (1976) proposed a model based on adaptation. It works from the premise that each person is constantly adapting to an ever-changing environment. Roy suggests that an altered state of health requires a person to adapt to cope with changed circumstances. She sees the role of the nurse as one of facilitating adaptation in the patient by adopting a systematic series of actions, directed towards the goals of adaptation. The role of the nurse in this model is to facilitate the patient to adapt to their altered health circumstances and through adaptation learn to cope with the change. This explanation is much over-simplified but it indicates yet another conceptual approach.

        Neuman’s Systems model (Neuman 1989) takes a very different conceptual approach, based on wellness. It is concerned with the patient’s response to stressors in the environment. Each person develops a range of responses to cope with normal circumstances, with some people appearing to cope better than others with everyday life. There are, however, situations that occur in the lives of all people that deviate from normal and produce stressors that are very difficult to cope with. Neuman defines stressors as inert forces that have the ability to impact on the patient’s steady state (Neuman 1989: pp. 12, 24). Some situations may be positive and enabling whilst others may be detrimental. This model views the nurse’s role as intervening to enable the patient to maintain an optimal state of wellness. There may be opportunities in primary care practice to capitalise on facilitation and enable the patient to manage stressors that face them in order to attain an optimum state of health. Such a model may be well suited for use in school nursing, health visiting and occupational therapy.

     In Peplau’s Interpersonal Relations model (Peplau 1988) the key components are the interpersonal process, nurse, patient and anxiety. Peplau considers that people are motivated towards self-maintenance, reproduction and growth by biological, psychological and social qualities. The model views the interpersonal relationship between nurse and patient as the focal point of interface that will produce benefits for the patient’s health. There are elements of adaptation and coping in this model with the main thrust of nursing intervention coming through the nurse–patient relationship as a therapeutic interpersonal process. A model such as this, based on interpersonal relationships, may be well suited to mental health and learning disability nursing.

        The conceptual models that have been mentioned in this chapter serve to illustrate the wide and varying approaches that contribute to the development of models of nursing. The differing approaches afford choice in decisions that are taken about delivery of care, and consideration should be given by the care team to the most suitable choice of model for the patient. The models are complex and to use any one effectively it will be necessary to refer to texts where the model under consideration is fully examined. It will also be necessary to make sure that others involved in the care know and understand the model in all its aspects.

THE NURSING PROCESS: A MEANS OF IMPLEMENTING NURSING MODELS

          The vehicle for implementing a nursing model is the nursing process, a functional approach to the organisation of nursing care. Yura and Walsh (1967) identified a number of stages in nursing care with which all nurses have some familiarity: assess, plan, implement, evaluate. The four stages of the process are used in conjunction with a nursing model and its philosophy. Using Orem’s model as an example, the four stages of the nursing process could be applied as follows.

The assessment stage of the nursing process would take into consideration:

• the philosophy that people are normally self caring

• the ability of people to care for themselves, using universal self-care needs to guide the assessment

• recognition of the reasons an individual may require nursing intervention

• recognition of the way in which lifestyle and the patient’s environment influence the situation.

The care plan would detail:

• the actions that need to be taken to meet identified needs in relation to the patient’s normal lifestyle and wishes

• interventions that could be used to achieve self care, whether they are the responsibility of the nurse, the patient or others

• the type of intervention needed: for example, teaching how to carry out care, or giving care, and providing aids to living that enable the patient to regain independence

• ways in which the planned actions would be evaluated.

The planned care would then be given (implemented), bearing in mind that:

• planned care is given according to good practice;

• current knowledge that is evidence-based underpins the care

• lifestyle and the environment are accommodated in the provision of care

• care given is evaluated against changes in the patient’s physical, psychological and socio- economic condition.

Evaluation of care takes place to determine its effectiveness. This is:

• carried out as an ongoing practice at each visit

• includes, at regular predetermined intervals, an objective review of the care with reference to changes in condition, treatment effectiveness,

introduction of new treatments

• leads to an adjustment of the care plan, if necessary, updating it in accordance with the evidence of the review.

     Thus the nursing process, systematically applying a model, connects theory to what is done on a practical level; and the nursing process and model(s) of care offer a care team a more supportive structure than can be provided by a task-oriented approach to nursing. They enable systematic, logical organisation of care to be developed around a philosophical focus.

     Though we are here referring to ‘nursing process’, in fact the four-stage process outlined above can be applied to any situation that requires organizing. It is a tool that can be just as useful for organizing a charity walk or planning a teaching session.

       Through the use of models of nursing and the nursing process there is good support on which to base nursing and health care practice, in a well  planned manner. All nurses must be thoroughly conversant with models and process, but although these provide a philosophy of care and give structure to care, what else is needed to provide sound practice? Evidence from patient surveys suggests that patients would want competent and caring practitioners (Carey and Posovac 1982) and the next part of this chapter is concerned with competent practice.

EVIDENCE-BASED PRACTICE (EBP)

          You are taught in formal and informal situations. You read professional journals, books, literature from medical suppliers and drug companies. You observe those who you work with, some of whom you admire as role models. As you progress through your career you gain from experience. Many things that you have done have worked well and the patient has had positive outcomes from your care. These positive outcomes are sources of learning: you learned from something that went well. Learning can also take place following a poor experience. If something did not work well or went wrong a great deal can be gained from reflecting on the event, identifying what went wrong and considering measures that could be taken to improve the situation.

Objectivity in Nursing Practice

         Learning takes place in a variety of ways and everyday work provides a mixture of objective and subjective learning experiences. Information that is evidence-based has been based on research studies, and this is objective knowledge, gained from systematically established evidence. Subjective knowledge is gathered from observations made in practice, from conversations with colleagues and sometimes from teaching sessions. The problem with knowledge gained in this way is that it may not be reliable, and could even be unsound and dangerous. It is important that care is planned on the basis of objective evidence, and this means that knowledge that is gained subjectively must be checked to see that it supported by evidence.

     EBP, a key concept in modern health care, is one element of clinical governance (DOH 1999), a framework for the continual improvement of services and quality in the NHS, the purpose of which is to ensure that clinical decisions are based on the most up-to-date evidence and that clear national standards are set to reduce local variations in access to and outcomes of health care. Clinical governance has the following key elements:

• To set national standards for health services through development of national service frameworks and the National Institute for Clinical Excellence (NICE).

• To provide mechanisms for assessing local delivery of high-quality services, reinforced by a new statutory duty to quality.

• To provide support for life-long learning.

• To develop effective systems for monitoring the delivery of quality standards in the form of the Commission for Health Improvement, the NHS Performance Framework and surveys of patient/user experience (DOH 1999).

All health professionals are accountable for their individual practice and are responsible for making sure that their knowledge and skills are current. This implies that any care given is based on the most up-to-date knowledge available.

         EBP forms an essential element in the quality of health care and is directly related to clinical care in that clinically effective practice is based on national standards, frameworks and research.

A Systematic Approach to Acquiring Evidence

        Systematic acquisition of evidence provides the information from which standards and protocols for care are developed. Standards and protocols related to the provision of care are written by employers to guide the process of care. Health trusts use national guidelines based on the work of the National Institute for Clinical Excellence (NICE) and evidence from research as the basis for protocols. Each employee has a duty to keep up-to-date with, and refer to, guidelines that are supplied by their employer to inform their specific area of care, and to work to protocols.

       Research is the means of gathering evidence, and thus the source of guidelines and protocols. Nurses should have a working knowledge of the research process to enable them to appraise and understand the evidence that is presented as the basis for care, and be able to make a judgement on validity.

        McInness et al. (2001) suggest that evidence is not easily integrated into practice. The reasons that they offer for this are that research literature can be poorly organised and not easy to read, making it particularly hard for busy practitioners to access. The same authors also acknowledge the poor quality of some research. These comments make it clear that evidence is not always easy to access/understand, neither is it always sound. Health professionals must be able to interpret the information that is given to them to enable them to question evidence when it is unclear or unconvincing. The application of EBP lies with each health professional who must exercise judgement about the applicability of knowledge, whether it is evidence-based or subjective. Senior members of the team should have sufficient knowledge to support less experienced nurses, but all registered nurses should have a working knowledge that equips them to question the soundness of practice.

     A part of professional life must be the acquisition of knowledge that informs patient/client care. Access to information through electronic journals and websites makes information readily accessible. Most health trusts have access points for internet searches and this makes it so much easier for nurses to keep informed and current in their practice.

Evidence-based care or patient preference?

       There may be some instances where a treatment or practice, even though based on evidence, may not be appropriate for a patient. Thought and consideration are required to be given by practitioners at each care intervention. This makes the argument for evidence-based practice turn on itself. You may reasonably ask why objective evidence cannot be applied in all cases when it is likely to be effective. The response to this rests in the nature of health care practice, which is described by McCormack et al. (2002) as practice that takes place in a variety of settings, communities and cultures. To add to this complexity, there are other relevant influences, for example psychosocial and economic factors. Taking all these factors into account it is reasonable to assume that thought needs to be given to the application of practice. While practice should be based on evidence, it is also important to establish that the patient is suited to this care, and willing to accept the proposed treatment.

Informed decisions and patient choice

       One example of advocated treatment being found unacceptable to the patient, would arise in the case of a family who do not wish to have their child vaccinated with the triple measles, mumps and rubella (MMR) vaccine. The family might hold strong views about the safety of triple vaccine. Here the parents’ wishes might conflict with those of professionals, who have convincing reasons why children should be protected from childhood infections. There are no easy answers to this type of problem, and decisions taken must be carefully considered in the light of evidence that is presented from a range of sources. The patients’, or in this case the parents’, wishes are vital. When decisions about care are to be made the nurse’s role is to provide information that can enable the patient to make an informed decision, but in the end the choice rests with the patient.

     Planning decisions about care are normally considered by the care team, and a long-term treatment plan, though initially developed by one nurse, would not rest with a single individual. The plan would be discussed by the team to ensure that it was suitable and allow all team members to understand the goals and process of care. Daily evaluation of circumstances would, however, rest with an individual and would rely on informed decision making.

      Professional practice relies on nurses being competent in a range of specified outcomes (UKCC 2001), successful achievement of which equips nurses to practice. Practice requires that decisions are made, and that implies that each professional should be knowledgeable in their subject area and have the ability to translate their knowledge to support practice. Knowledge in itself has only limited value if it is used without due consideration of the effect that it might have on a situation. Thus a key aspect of professional practice is the ability to interpret and apply knowledge in widely varying circumstances. It is around the varying circumstances that decisions must be made that assure that care is appropriate and each nurse is accountable for the decisions that they make about patient care (NMC 2002).

LEARNING THROUGH REFLECTION

       Many of the issues raised in this chapter illustrate the complexity of nursing practice and demonstrate how thinking skills and decision making are essential to good practice. Not only is nursing practice complex it is also dynamic, and changes with developments in health policy and scientific knowledge. For nurses this means that every patient contact is unique and that over a period of time a great deal of experience is generated from nursing practice. Nursing practice, taken in its widest sense, means working with other health and social care practitioners to provide the assessment, organisation and management of holistic care for patients.

     Reflection is a great way to learn. It enables nurses to capitalise on what they do well and see how to improve the aspects of care that did not go so well. Taylor (2000) stresses this by stating how the unconsidered life is transformed, through the process of reflection, into one that is consciously aware, self-potentiating and purposeful. All recently qualified nurses will have been taught to use reflection as a method of learning, for just as EBP is a key concept in current nursing practice, so is reflection. Reflection has particular value to learning in nursing because of the richness of experience in practice and the direct observation that nurses are able to make about how the care that they and the health care team give affects patients.

Reflection and practice

       Reflection can and should take place during the process of practice. Schon (1983) refers to this as ‘reflection in action’. It also takes place after the event, which Schon refers to as ‘reflection on action’. Sometimes reflection is private, at other times it is shared with colleagues or may even form part of a team meeting.

       The exercise that you have undertaken is an illustration of reflecting on practice, learning from it and using the learning to inform and develop future practice. This is why reflection is so beneficial in nursing. In part it is explained because of the uniqueness of each situation demands new thinking and reasoning and this accumulates over time as experience increases.

      Reflecting on action is a deliberate event. It can be a very effective learning experience for the individual nurse or for the team. Each nurse should regularly take time to reflect on their practice, considering their knowledge and skills, the evidence base from which care is given and the many influences that impinge on care.

     Group reflection probably occurs informally in many teams at hand-over meetings when care is discussed. Reflection by the team in a more formal sense provides opportunity for review of patient care on a planned and regular basis. Like the individual nurse, the care team considers their knowledge and skills, the evidence base from which care is given, the influences on care, that are raised in models of nursing, and take a general reflective view of the care provided for each patient. Group thinking can be productive, with each member contributing an individual perspective, and everyone learning from the others in the group. Shaw (1981) suggests that groups make better- quality decisions than individuals, which has particular significance when so much is at stake for patients. However, some caution needs to be exercised when a group reflects, on account of a phenomenon known as groupthink, whereby pressures for conformity and for keeping within the boundaries of accepted practice stifle creative thinking (Robbins 1986).

     Learning often occurs when something happens that is disappointing or does not turn out the right way. It is this type of experience that most frequently makes people think about what they have or have not done and how it could have been more effectively achieved. It is not enough only to reflect and recognise where things went wrong: that is evaluation of the incident. Reflection is more than evaluation – it involves new learning. For learning to occur it is first necessary to identify what, in the case of a negative experience, went wrong. It is then essential to take the necessary steps to remedy the deficit and put it right. It may be as simple as recognising that work has been done without sufficient thought and that corners have been cut. In this instance the practitioner knows what should be done but has failed to do it correctly. The learning will be in the nature of accepting that however great the pressures, sufficient time must be given to each patient and procedure. It may, however, be that new learning needs to take place, perhaps a new skill needs to be learned, maybe from a colleague who has the necessary expertise. Sometimes knowledge is out of date and must be updated by reading or by attending study days. Very often in primary care nurses come across health problems that are new to them and they have to find the information that is needed to enable them to provide effective care. As you can see, learning involves taking some action. The purpose of reflective practice is to actively enable learning so that it becomes integral to routine practice. If a nurse constantly reflects on practice, learns from it and changes practice in response to learning, practice will not become static and out of date.

Aids to reflection

A number of frameworks have been designed to help the process of reflection. Many nurses are introduced to reflection by using the staged process advocated by Gibbs (1988). Gibbs’s model offers a cycle to guide nurses through the reflective process:

• describe what happened

• explore the thoughts and feelings that occurred as part of the experience

• evaluate what was good and bad about the experience

• analyse the experience in order to better understand it

• consider what else could have been done, and finally

• make an action plan to determine how the situation would be handled should it occur again.

       This cycle of steps gives an easy-to-follow process, guiding the nurse through reflection. There are other frameworks that facilitate the reflective process, for example Burnard (1991), Boud, Keogh and Walker (1985) and Goodman (1984). Goodman’s approach focuses on levels of reflection, suggesting three levels of increasing complexity. The first level consists of a simple approach that involves considering how the job was done with regard to technical efficiency and effectiveness, and in terms of accountability. The second level takes a wider view, looking at the implications and consequences of the nurse’s actions and beliefs, which includes the underlying rationale for practice. The third, most complex, level draws on all the considerations in levels one and two, and adds ethical and political considerations and developments.

       There are distinct differences between the approaches that are taken by Gibbs and Goodman. Gibbs offers a framework to facilitate structured thinking while Goodman pushes the boundaries of thinking to levels of considerable complexity. Examination of different approaches helps nurses to choose the one most suited to the situation. As with models of nursing the most suitable approach to reflection may vary with differing experiences and so it is beneficial to have a range of approaches to draw upon.

CONCLUSION

        This chapter has covered some of the key factors that influence and inform professional practice in nursing. This should create awareness of sources of nursing knowledge and reinforce earlier learning that introduced the nature and purpose of nursing models. There is no doubt that practice is complex and nurses can only truly attempt to meet the needs of patients if they are able to understand and manage complexity. The value of models of nursing is that, in representing the complex nature of practice, they act as prompts. Because each model is presented in diagrammatic form it enables the same detailed process of assessment, planning, implementation and evaluation to take place for every patient. Professional skill comes into play as infinitely variable information is analysed and interpreted into personal and individual plans of care that take account of very differing needs. The skill of the nurse is needed to manage patient information and translate it, with the patient’s collaboration, into meaningful and appropriate delivery of care. Nurses must therefore be knowledgeable and skilful. The dynamic nature of health care means that new knowledge is constantly emerging, and health practitioners are obliged to keep up to date with the latest developments.

         Knowledge and the validity of information are requirements for planning effective, economic care. Quality in care is high on the government agenda for improving the National Health Service (DOH 2000). Receiving care that is based on objective information is an essential part of provision; application of care without thought or consideration of the individuality of people would go against the ethos of professional practice (Norman and Cowley 1999). Norman and Cowley state that knowledge based on evidence is valuable and should underpin protocols and guidelines. Information that is collated and current greatly assists practitioners. Blind acceptance of evidence is not, however, consistent with professional practice, one criterion of which is autonomy. Reflective practitioners who are constantly learning on the job are fundamental to the profession – nurses who can plan appropriate care on an individual basis, with the patient, and are able to be justify their decisions.

 

 

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VI. Working Collaboratively

 

 

INTRODUCTION

           The ability to work collaboratively has been highlighted in the professional Code of Conduct (NMC 2002a) as an essential part of a nurse’s role. There is an expectation that a nurse will work co-operatively with other professionals, respecting their skills, expertise and contributions.Additionally, a nurse must communicate effectively to share knowledge, skills and expertise in order to work efficiently with other team members, whilst maintaining high standards of care (NMC 2002a). Nurses who seek to enrich their practice need to have a greater understanding of what it means to work collaboratively, not just with other professionals but primarily with patients and their carers(Fatchett 1996). This active involvement of patients in their care lies at the heart of current government policy (DOH 2001a, 2001b). Whilst the aim of collaborative working is that it should lead either to health gains or improved patient outcomes, it must be noted that there is, according to Ross and Mackenzie (1996), insufficient evidence to date to substantiate this view – an interesting finding given that policy and practice place such emphasis on collaborative working.

          The following case study of a hypothetical family in receipt of primary care will be used to contextualize the issues being discussed.

Example

Elmer King, aged 35 years, is black British of Caribbean origin but grew up in London. He is unemployed, suffering from schizophrenia and carries sickle cell trait. His partner Ann, aged 32 years, is white British. She also carries sickle cell trait. She has a part-time night cleaning job for a large local firm.

 

 

Malcolm Roberts, aged 13 years, is the son of Ann’s first partner. He is timid and small for his age. He ‘gets picked on’ by other children at school and has recently been complaining of stomach aches and not wanting to go to school.

Louise King, aged 8 ye

ars, has sickle cell disease and has had a lot of absence from school because of sickle cell crises.

Alice King, aged 11 months, is wheezy and suffers from severe infantile eczema. She was bottle-fed from birth and weaned very early. She has attended for developmental checks. Her hearing and vision are satisfactory but there is concern about delayed motor development.

Ann recently scalded her leg badly. She says she accidentally knocked over a full pot of freshly made tea. She has been self-treating the wound for a few days and has only just visited her general practitioner (GP) as the wound is now ‘rather smelly’ and her leg is very red.

The family live in an urban area of a large city. Their accommodation, which they rent, is a small terraced house with two bedrooms and a small garden at the rear.

 

In considering issues relating to Elmer, Ann and their family there is the potential for a number of different people to be involved in order to provide the appropriate services to meet the family’s health and social needs.

IMPLICATIONS OF GOVERNMENT POLICY FOR COLLABORATION

         Over the past 15 years, government health and social policy has constantly reinforced the need for primary health care and teamwork to meet the challenges of a changing population and of ‘life- style related disease in the community’ (Ross and Mackenzie 1996: p.78). In 1986 the Cumberlege Report (DHSS 1986) noted that numerous health and social care professionals were ‘beating the same pathway’ to patients. The results were confusion for the patients and their carers and duplication of services. It was considered that the service provision was fragmented and the potential for missing health needs was significant. Through a series of government policies (DOH 1987, 1989a, 1989b, 1990, 1996, 1997, 1999a, 1999b), teamwork, collaboration and a partnership approach to care have become central to the provision of care in the community. There is recognition of a need to move away from the traditional boundaries of health and social care towards the development of multi- professional teams working throughout hospital and primary care settings.

        The NHS and Community Care Act 1990 brought together the social services and health services to provide ‘seamless care’ to people in their own homes or in homely settings. The Act provided a ‘planning framework’ to enable different agencies to work together, to consult and collaborate at every level (Audit Commission 1992). This ‘bringing together’ was further strengthened in the subsequent government report, Primary Care-Led NHS (DOH 1996). It was envisaged that multi-disciplinary, multi-professional, inter-agency teams of people would be working together. In a time of diminishing resources and increasing demand they would provide an effective, high-quality care that would be needs led and not merely a blanket provision.

           It was the change of government in 1997 that brought about recent changes of policy in the National Health Service, but the need for partnership and collaborative working has remained a significant feature – in fact has been emphasized more strongly. One of six key underpinning principles outlined in The New NHS: Modern, Dependable (DOH 1997) was to involve the National Health Service in partnership with other agencies in the provision of social and health care, with the needs of the patient at the centre of the care process. The increasing emphasis on the role of primary health care teams has come about as a result of ever-increasing hospital costs alongside government recognition of their importance as gate-keepers to health care (Fatchett 1996). The more recent NHS Plan (DOH 2000) has contributed to this shift in emphasis to a needs-led service – one that encompasses collaboration, joint working and partnership. Fatchett (1996) has attributed the increase in popularity to collaboration to a number of causes.

  • A growth in the complexity of health and welfare services.
  • Expansion of knowledge and subsequent increase in specialization.
  • A perceived need for the rationalisation of resources
  • A need to reduce the duplication of care
  • The provision of a more effective, integrated and supportive service for both users and professionals

           The greater complexity of technology and treatment has placed tremendous pressure upon practitioners to have the necessary knowledge and competencies to meet the needs of patients with complex care needs. There have been a number of recent public inquiries into incidents involving people who have been diagnosed as mentally ill. Government response has been to seek to improve the co-ordination of care for such individuals, with an increased emphasis on the role of the primary health care teams (Secker et al. 2000).

DEFINING COLLABORATION

                As highlighted in the previous section, the reasons given for collaborative working would seem to be extensive and significant, but what does it actually mean? The word ‘collaborate’ is derived from the Latin collaborare which means ‘to labour together’. This notion of working together has been highlighted by Ovretveit (1997) in the sense of collaboration between organisations or individuals working together or acting jointly. In addition, the notion of exchange is evident in Armitage’s definition (1983), defining collaboration as being the exchange of information between individuals involved in the delivery of care, which has the potential for action or joint working in the interests of a common purpose.

             This definition would seem to be quite straightforward, but it could also be seen to be referring exclusively to professionals delivering care without reference to the patients and their carers. Interestingly enough, the issue about being professionally driven could be inferred from policy documentation (DOH 1992). Here collaboration is seen as a ‘partnership of individuals and organisations formed to enable people to increase their influence over the factors that affect their health and well being’, a view more recently expressed in The NHS Plan (DOH 2000) and Liberating the Talents (DOH 2002).

              The issue of collaboration having the potential to be professionally driven is of particular importance when considering a partnership approach between practitioners, patients and their carers. Henneman et al. (1995) suggest that when individuals are involved in collaboration their relationship is non- hierarchical. Power is shared on the basis of knowledge and expertise rather than role or title. In other words, collaborative working needs to involve a redistribution of power within the health care team (Soothill et al.1995).

THE INTERFACE OF COLLABORATIVE CARE

           In considering the needs of Elmer, Ann and their family there will be a need to relate to and work with each member of the family as well as networking with a range of diverse groups, including social services, and voluntary agencies. The interface may be at different levels, according to the actual requirements of care. Armitage (1983) identified a taxonomy of levels of collaboration that moves from a situation where people communicate without meeting to a situation where people work together. For example, issues of child protection and bullying that could be associated with Alice and Malcolm might be dealt with by the health visitor and the school nurse, who might also involve such other agencies as social workers, the police and the judiciary. The GP and the practice nurse may be involved with the care of Ann’s wound and for Elmer’s maintenance medication. In this way referrals from one agency to another regarding the family might occur without any need for a meeting. However, if the care is to be effective it might be that each of the agencies involved would need to come together and meet with the family to resolve difficulties, duplication and problems. Similarly, two agencies might be more involved than others and take the lead in the care whilst informing the remaining agencies of progress.

          A framework for classifying collaboration by Gray (1989, cited in Huxham 1996) suggests that there are two dimensions: factors that motivate people to collaborate and the goal or anticipated outcome of the collaboration. Gray further suggested that there are four types of collaboration: appreciative planning, dialogues, collective strategies and negotiated settlements. Although Gray is concerned specifically with business organisations, her classification of the four types of collaboration could also be applied to health care situations.

            The different types of collaboration as identified by Gray can be seen at a micro level, as in the King family. The exchange of information is one of the key features in the King family’s situation (appreciative planning). Each of the different practitioners involved with Elmer, Ann and the family care need to communicate (dialogues) their knowledge of the situation in order to arrive at a shared vision. They need to provide an arena for exploring solutions to the problems identified by the patients and their carers, resolve difficulties (negotiated settlements) and reach agreement about a plan of care (collective strategies). Thus the collaborative process will pass through three phases: problem solving, direction setting and implementation (Gray 1989, cited in Huxham 1996).

           At a broader macro level, working in partnership and collaborative care means ensuring that the structure of the organisation is sufficiently flexible to support patients and enable them to function. The implementation of health improvement programmes (HIPs) is seen as providing the ‘strategic glue’ that binds the different services together in new working partnerships between users and health service providers, including statutory and non-statutory (Gillam and Irvine 2000). In addressing the needs of local populations through HIPs there is an emphasis upon primary care staff to work across practice and professional boundaries with colleagues in Social Services, Education and Housing. In this way, people with the relevant knowledge and skill, including the patients and their carers, will be able to carry out the appropriate care.

SKILLS NEEDED TO COLLABORATE EFFECTIVELY

         Previous sections of this chapter have discussed why it is important to work collaboratively, what it means to collaborate and with whom we need to collaborate. This section is about how we collaborate – in particular the skills needed to collaborate effectively. Using the case study of Elmer, Ann and their family, scenarios will be drawn out to demonstrate the range of skills that are fundamental to effective collaboration.

       Hornby and Atkins (2000) are clear in establishing that the sole purpose of collaboration is to provide optimum help. In their discussion on collaborative processes and problems, they identified a range of attitudes and skills necessary for good practice. It is these that will be identified and integrated in an examination of this complex family situation.

         Thompson (1996) states that working with others involves engaging with other people person- to-person. However, before we can do this we have to have a good understanding of ourselves in terms of ‘how we are perceived by other people, our characteristic responses and reaction and our own needs’ (p. 234).

Collaborative Attitudes

Hornby and Atkins (2000) suggest that collaborative attitudes may be clustered under the concepts: reciprocity,flexibility and integrity.

  • Reciprocity is based on respect and concern for individuals and the development of mutual understanding and mutual trust.
  • Flexibility is the readiness to explore new ideas and methods of practice and an open attitude to change. It is about working in partnership with clients and colleagues and not about positions of power.
  • Professional integrity places the client’s needs first and not those of the individual practitioner. Integrity, according to Hornby and Atkins, demands that practitioners examine their own defensive practices and separatist tendencies.

            This scenario highlights the importance of collaborative attitudes. In considering the issues of reciprocity, flexibility and professional integrity, you may have covered the following issues.

            Reciprocity. The practice nurse has shown genuine concern and empathy for Elmer. She has begun to build up a relationship with him during his routine appointments and her knowledge of his condition has led her to feel genuine concern. In the busy schedule demanded by the appointment system at the surgery, it would be easy to label Elmer as a ‘DNA’ (did not attend) and be somewhat dismissive of any follow-up. Mutual trust is beginning to develop between the practice nurse and Elmer and the fact that she has been unable to contact him on the phone, has led her to feel that ‘something is wrong’.

        Flexibility. The practice nurse has shown by her actions that she sees Elmer as an equal partner in his care. Her approach is one of working towards concordance (see DOH 2001a) as opposed to compliance. She would be keen to consider other methods of practice, depending on Elmer’s needs.

             Professional integrity. The practice nurse has demonstrated the importance she places on meeting Elmer’s needs – it would have been easy for her to become irritated by Elmer’s ‘DNA’. In terms of her role within the practice and the other patients she has been more prepared to consider what is wrong with Elmer than her own position at that time. However, she should also realise that she is not alone in being able to provide support for Elmer. She is a member of a wider primary health care team, some of whom might be better placed to follow up Elmer’s situation. In this way she would be demonstrating her awareness of her own role and its boundaries whilst respecting the roles of the others in the team.

Exercise:

Consider what reciprocity, flexibility and professional integrity would mean in relation to the following scenario.

Elmer usually attends the health centre for his regular depot injections from the practice nurse. He has not attended for the second injection and the nurse is very concerned about Elmer. She has tried to contact him by telephone but the number is unobtainable – in fact it has been cut off due to non-payment of bills.

           Elmer’s community mental health nurse would probably be the first colleague to contact regarding his schizophrenia and depot medication. She might also want to discuss the situation with her health visitor colleague, who would know the family because of visiting Ann and baby Alice. Both these colleagues would be able to discuss Elmer’s financial situation with him and seek further support from the social worker, should he wish it. She could also contact the school nurse responsible for the schools that Louise and Malcolm attend just to ensure that the children have the opportunity to share any concerns if they wish and to monitor their situation.

       In summary, this scenario demonstrates how important it is to have a positive attitude to collaboration not only with patients but also with colleagues.

Collaborative Skills

      In addition to collaborative attitudes, Hornby and Atkins (2000) highlight the importance of  collaborative skills and see these as relational, organizing and assessment skills – all essential elements for effective collaborative working.

        Relational skills include open listening, empathy, communicating and a helping manner, in other words putting people at their ease.

      Open listening means hearing without stereotyping, and using direction purely for the purpose of hearing more rather than less. It requires the ability to tolerate distress and anxiety without resorting to coping methods that restrict the client’s communications. It means being alert to the feelings that may be involved when individuals seek and receive help and being aware of the effect on people of finding themselves as a service user. It is about facilitating the expression of relevant emotions and being able to empathise whilst at the same time retaining the necessary objectivity when meeting patients’ needs.

       Empathy, according to Thompson (1996), is the ability to appreciate the feelings and circumstances of others even though we do not necessarily share them. It is about being sensitive to differences and avoiding making stereotypical assumptions. In order to avoid discrimination and disadvantage, it is essential that patients’ differing requirements are met.

       Clements and Spinks (1994) stress the importance of treating others, whether as individuals or in groups, fairly, sensitively and with courtesy, regardless of who they may be. Further, they identify the following skills, knowledge and attitudes, which are applicable to almost any situation:

• empathy

• keeping within the law

• thinking about the consequences

• not believing myths

• a desire to be fair

• openness to different ideas

• reflective thinking

• sensitivity

• using appropriate language

• knowing about the issues

• treating people as individuals

• not seeing alternative cultures as a threat

     Open communicating means conveying what seems to be relevant, including feelings as well as facts and opinions, without becoming defensive. Where trust is lacking, defensive processes and protective devices are likely to come into operation. Open communicating also relates to the need for professional confidentiality (NMC 2002b). For further information about confidentiality see Cornock (2001).

       A helping manner, according to Hornby and Atkins (2000), is the ability to manifest personal concern and professional confidence without superiority, thus enabling patients, carers and practitioners to function at their best in a working relationship. The role of carers should not be taken for granted nor undervalued: the practitioner must be as concerned for their wellbeing as for that of the patient. This feeling of being valued may not automatically result in an increased participation but it can at least bring emotional benefit to both carer and patient. Facilitating patients’ and carers’ expressions of their feelings is a skill which can often increase understanding of a situation, resolve blocks to progress and relieve tension and distress.

Exercise:

In terms of relational skills, for example open listening, communication and a helping manner, what do you feel are some of the issues in the following scenario?

The district nurse has received a referral from the GP regarding visiting Mrs King, who has recently scalded her leg. She has been self-treating the wound for several days and it has now become infected. The district nurse has not had any previous contact with Mrs King.

Mrs King has a night-time cleaning job for a large local supermarket and with her family commitments is not able to attend the health centre. The district nurse knocks hard on the door and eventually Mrs King appears in her nightie, looking cross. She was asleep and Elmer, who should have been looking after baby Alice, has gone out.

          You may have considered some of the following points. At the initial referral it would have been helpful if the GP had indicated that Mrs King worked ‘nights’. Even though she could not confirm her visit by telephone the district nurse should have been able to make a visit at a time more convenient for Mrs King which intruded less on her need to sleep during the day. It might have averted the initial ‘angry’ meeting. However, once in this somewhat confrontational position, the district nurse needs to be able to acknowledge the situation as a whole and her role in it. She needs to be receptive to Mrs King’s irritation and demonstrate her open listening skills. It would be easy to become defensive and use closed questions as a means of restricting Mrs King’s communication. Skills in open communication are essential in order to build a trusting relationship between practitioner and patient. A helping manner is demonstrated by concern for the individual patient within the wider family context. This example shows how important it is for the practitioner to view a situation from a holistic perspective rather than from a limited task viewpoint. In an uncomfortable atmosphere the practitioner could well have undertaken a specific task and then left, limiting her concern solely to Mrs King’s leg.

        Organising skills identified by Hornby and Atkins (2000) are those required to implement the principles of essential collaboration. These include establishing networks, setting up meetings, devising appropriate patient/carer referral systems, and managing changes within the work context. Professional boundaries need to be clearly defined and agreed. Henneman et al. (1995) maintain that collaboration requires individuals to have both a clear understanding of their own role and an understanding and respect for the roles of others.

       When individual team members are clear about their own roles and boundaries and those of others in the team, the most appropriate person can then support Elmer and his family – otherwise gaps in their support could appear. The complex situation presented by Elmer’s family requires an effective application of skills. The family, the GP, practice nurse, receptionist, community mental health nurse, district nurse and school nurse have already been indicated as each having a role to play. Clearly, networking with others in such a situation is crucial. The primary health care team meeting could prove to be a valuable forum where issues would be shared, future support for the family clarified, and the key worker identified. A lack of organisational skills could prevent a full and accurate picture of the family’s needs being completed.

          Assessment skills represent the final element of collaborative skills as identified by Hornby and Atkins (2000). Assessment, according to Thompson (1996), is a complex and multi-faceted process. A high level of interpersonal skills is required when undertaking a holistic assessment, and in complex situations assessment skills involving a range of perspectives may be appropriate. When different agencies have overlapping boundaries sometimes the patient can experience difficulty in finding that which is most suited to meeting his/her needs. At the same time it is not always possible for one practitioner to have sufficient in-depth knowledge of the various contributions of other agencies. Practitioners need to know enough about a range of services to be able to select the most appropriate one for any given situation and also when to refer the patient. Thus, the demands on the practitioner include not only a wide range of knowledge and a high level of assessment skills but also a freedom from defensive or separatist attitudes (Hornby and Atkins 2000). Whilst there is a desire to move towards a single assessment process, currently different professionals have their own methods for documenting assessment (NMC 2002b). It is the pooling of this information that is so important to ensure that all the pieces of information fit together.

INTERPROFESSIONAL RELATIONS

The final section of this chapter focuses on interprofessional relationships, thus drawing together some of the wider issues already alluded to.

            Mackay et al. (1995) have asserted that working interprofessionally involves crossing traditional professional boundaries, being prepared to be flexible in considering a range of views and having a willingness to listen to what colleagues from other disciplines are saying. Each group brings different skills and solutions to the health care problem with which they are presented. In some decisions the contribution of one professional group needs to take precedence over others, which underlines the need for flexibility in decision making. Interprofessional working, as mentioned earlier, raises the question of redistribution of power within teams. So many fundamental changes are taking place within primary care that perhaps now is an opportune moment to challenge established and entrenched attitudes.

           Collaboration between professionals and between service agencies is currently regarded as the cornerstone of the development of community care in the UK. However, only recently have mechanisms of collaboration been subject to evaluation as a means of demonstrating effectiveness. Molyneux (2001) attempted to do just this in her study of interprofessional team-working by identifying and evaluating the positive characteristics of team working. Three main themes emerged:

• Motivation and flexibility of staff. Personal qualities of staff such as flexibility, adaptability and lack of professional jealousy enabled team members to work across professional boundaries.

• Communication within the team. Findings identified regular and frequent team meetings and agreement on the communication strategies, for example shared records, within the team as central to effective team working.

• Opportunities for creative development of working frameworks. Encouragement and opportunities need to be provided for staff working together to enable them to develop creative methods of working which meets their patients’ needs.

           It is in the sharing of knowledge and skills in a collaborative way that the common goal of holistic care is more likely to be achieved with ultimate benefits to the patient and family. (Shields et al. 1995). Essential to the success of collaborative working is a defined mechanism for making decisions. Problems can occur where a team does not have a clear and agreed process. Ovretveit (1993) points out that conflict can arise unless differences are aired and worked through in a creative and fair way. Unstructured decision making procedures waste time, cause conflict and resentment and can lead to team break down.

         In summary, collaborative working is an ideal that essentially seeks to ensure that the best interests of the patient are protected. It is a never-ending  process in which the patient, relatives and carers must increasingly be supported to play a central role in making their own contribution to decisions affecting their lives. Collaborative working is, therefore, one step on the way to fully informed decision making in meeting the needs of patients and their carers and delivering effective and efficient community health care.