Person Centred Care

gThis essay will reflect upon an incident that occurred whilst in placement at a Unit for Clients with behaviour and learning needs, and associated autistic difficulties. Clients are both sexes and range in age from four to eighteen. It will be undertaken, defining person centred care in relation to the incident, it will demonstrate awareness to roles and responsibilities of professionals in meeting the needs of the client and it will demonstrate the importance of inter-professional collaboration and discuss the issues that facilitate or act as barriers in this partnership.

In Order to Maintain Confidentiality the client has been provided a pseudonym (Nursing and Midwifery Council 2008). Permission was also granted from this client to use this information for the purposes of this essay. The Unit in which this Incident took place provides day care and education. Children follow the National Curriculum attend class and outside activities and are supported by Teachers and Learning Support Assistants.The aim of the unit is to remove barriers to learning and facilitate inclusion for the pupils of this unit. As the barriers to learning are multi -faceted, staff work closely with a range of support agencies to differentiate teaching and learning appropriately, (See Appendix 1) whilst in the unit the children attend sessions with Occupational Therapists and Physiotherapists. The incident relates to one such session with the Physiotherapist that the client in question did not want to participate in.On being called from the classroom to attend his “timetabled” exercise session Alex made it clear that he felt tired and unwell and did not wish to take part in this session.

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On further questioning Alex became agitated and abusive towards the teacher and learning support assistant as they were insisting that he needed to attend as it was within his timetable. Alex was taken to the session by both members of staff in his wheelchair against his wishes.The Mental Capacity Act (2005) provides a statutory framework for decision making thus protecting the vulnerable, it makes it clear who can make decisions in which situation and how they should go about it, it states that if the person has the capacity then all steps possible should be made to ensure the person is helped in making this decision ( Mental Capacity Act 2005) Alex was completely removed from the decision making process, unable to make this decision and no help was given to him to ensure that he made the correct decision.The European Convention of Human Rights (1998), states that each person has a fundamental right to be treated as Human Being and with dignity and respect.

The Governments White Paper Valuing People (2001) laid out that it would be essential to adopt a person centred approach to deliver a real change in the lives of those people with learning difficulties. (DOH 2002) it was based on four key principles Civil Rights, Choice, Independence and Inclusion and goes on to define those with learning disabilities in the following way “People with learning disabilities are people first” (Gray 2002).For people with learning disabilities there are even greater barriers of invalidation to be faced, for people with sensory or physical impairments they are likely to be deemed competent to both judge and articulate their needs, however for those with an intellectual impairment, such competence will always be open to question (Simons 1998). This clearly was the case in relation to Alex as he was not deemed competent to make the decision for himself.The right to a voice throughout history has been bestowed according the fluctuating perspectives of an individual’s ability to benefit from that right.

It is only in more recent times that the essential personhood of those with learning disabilities has been acknowledged (Gray 2002). About 60% of Adults with learning disabilities live with their families and their vulnerability and complex needs could mean that there could be difficulties in applying the principles of person centred care.Throughout the whole of their lives they are extremely reliant on family and care workers to make decisions for them, however Ruston(2007) in Koubel (2009) argues that by applying the principles of person centred care we show that person respect therefore increasing their sense of worthiness. (Koubel 2009)The aim of person centred care is to ensure that the patient is an equal partner with the health and social care professional.To begin with the person is the centre of the plan, to be consulted with and their views must always come first: It should include all aspects of their care, and every professional should work together to provide it. (Leathard 2000) Autonomy refers to an individuals’ ability to come to his or her own decisions and requires nurses to respect the choices patients make concerning their own lives (Hendrick 2000). However Gillon Argues that the principle respect for autonomy may need some restriction, otherwise we may be morally obliged to respect an autonomous course of action with nthinkable consequences.

( Gillon 1986) Every human being has an intrinsic value, they all have a right to well being, to self-fulfilment and to as much control over their own lives as is consistent with others (British Association of Social Workers 2002). Professional Judgement and patient preference cannot be suspended if practice is to be safe and effective rather than routine(DOH 2005) Alex had to attend this session as it was within his Timetable, how could it have been effective? , he was unhappy and uncooperative.Through person centred care we show respect by recognising individual choice and boundaries and through acknowledging the uniqueness of the person (Koubel 2009). The trust and collaboration with patients is derived not simply from the practitioners clinical focus and expertise, Communication Channels, Quality Standards, levels of co-operation and even explicit patient orientated policies are also now equally important ingredients. (Meads 2005) Working with individuals with a learning disability requires a psychological and often physical closeness which would not necessarily be required by a patient who is not cognitively impaired.

Promoting and maintaining professional boundaries is as important and arguably will be of greater concern, the Nursing and Midwifery Council Code of Conduct states that all time the nurse must maintain the appropriate professional boundaries (NMC 2008), however the main aim of those charged with the care of those with learning disabilities is to work in partnership with each other to support the well-being and social inclusion of those with learning disabilities, by improving and maintaining their physical and mental health.The more the patient is viewed as a partner in the care process the greater the likelihood that they can influence collaborative behaviour, (Meads 2005) however as Alex was not viewed as partner the collaborative behaviour was missing making the situation a tense and difficult one. Inter-professional work is vital if the complex and broad ranging needs of disabled people are to be met, indeed all service work for disabled people implies inter-professional collaboration if the complexities are to be fully met(Leathard 2000).Within the professional-client relationship both parties are unequivocally equal because they share the same humanity, however within this relationship the professional is deemed to have superior knowledge, whilst the patient may recognise this they may still wish to retain control and responsibility over the decision making process(Althea and Ewens 1998 ) Alex was not given control over this decision making process therefore the control and responsibility he may have wished to retain was taken from him.It is easy for professionals to rely on policies and procedures, leaving the service user on the outside of the interaction, (Koubel 2009) this is clearly the case of what happened to Alex the policy was that he needed to attend a session with the physiotherapist, as there was nothing in place to cover his timetable if he did not wish to attend he was forced to do something against his wishes. Our understanding from psychology suggests that different people can look at the same image yet see different things (Althea 1998).

In remembering that this was in a unit with other children, we can only comment on what we see and feel about the incident, however how aware, are we of the message being portrayed to others?. This Incident and the dealing of it was one of authority and procedures, maintaining a person centred perspective in the face of legal and procedural process requires an, awareness to and commitment to person centred values. (Koubel 2009)The emphasis on inter-professional collaboration has emerged as a direct response to health and social care policy in the late 1980’s requiring various agencies to work more closely together in providing, a needs led service. (Althea &Ewens 1998) The policies highlighted the difficulties that different professional groups had in working co-operatively, major legislative changes followed these included the Children Act and the NHS and Community Care Act.

As The Patient centred or person focused nature of the service was recognised, the commitment to collaborative teamwork to meet the broader nursing objectives of co-ordination and agreeing objectives for patient centred care meant that the question of inter-professional negotiation had to be faced (RCN 1987). Differing perceptions of the needs of the client both between, professionals and the, professional/client shows that it is essential for health care professionals to understand how each agency is managed and their operational procedures. Caldwell 2003) Had the teacher spoken to the physiotherapist it may have come to light that the session could have been missed, and another one made available when Alex felt able to attend. The teacher took over the decision making role basing the decision on the assumption that the session was needed for Alex’s health. The nurses’ code of professional conduct states that as nurses we must work with others to protect and promote the well being of those in your care (NMC 2008) it goes on to say that we must work cooperatively in teams and respect the skills and expertise of others.

The Health and Social Care Act (2001) placed a duty of partnership on health and social care organisations building on measures such as the integration of service provision (DOH 2001). Within the NHS plan there is a clear policy aim to break down the traditional barriers that limit healthcare professionals from working to their full potential (DOH 2000). The world health organisation defined the health team as a group who share a common objective determined by community needs.

WHO 1984) Being professional today means becoming inter-professional at its simplest collaboration it is about working together however it is also about relationships, the need is to work together and not just alongside to ensure strategic coherence for goals and priorities, it may represent a long term strategic commitment but may also apply to time limited task focused joint work. (Meads 2005)See Appendix 2) When a set of people work together the effect should be organised co-operation, an agreed planned working together toward a specific common goal. Leathard 2000) Teamwork according to the Harding report is fundamental (Harding 1981), team success relies on the contribution of all members. A Number of principles were identified from the development of the patient centred framework(RCN 1987) and the theoretical framework identified six important areas of activity which need to be recognised within the health care delivery system before shared objectives, and achievable standards can be set, monitored and evaluated (Kitson 1989) (See Appendix3).A number of different frameworks can be used to set standards; off these, the Avedis Donabedian ‘structure, process, outcome’ model has been widely adopted by the nursing profession. (See Appendix 3) Further development of other frameworks such as the Crosby” Process Model Worksheet “ and Maxwell’s “six dimensions of quality” have been used to formulate a multi-disciplinary setting of shared objectives. ( Parsley 1994) However in choosing an pproach in setting standards it is important to consider what the selected framework is to be used for as it may be more appropriate in some settings than others.

The principles of patient centred management can be incorporated into various management models however the aim of patient centred care is to enhance patient autonomy this, makes it a process of developing continuous quality improvement focused on the client need, the organising of healthcare workers into multidisciplinary task teams which can respond quickly and flexibly to the client. Heginbotham1996) (See Appendix 4) A number of external influences that work against inter-professional collaboration have been identified these include organisational structure, the education and development of professional groups, and the perceived social standing of various groups. (Althea&Ewens 1998)Working across professional boundaries may involve exchanging the role of expert to one of novice. (Naidoo 2008) People fall rapidly into the expectations they have about the roles they take in groups, a trap of roles is that they can literally take you over and you can forget your real values and believes. Changing Minds) Conflict can also arise between the ethical, legal, professional and organisational frameworks that guide professional practice. (Cauldwell&Atwal 2003) In relations between inter-professional groups some professions have more power and status, resulting in a perception by the more powerful group that they are better placed to respect and adhere to traditional professional practice. (Althea & Ewens 1988) The Thomas-Kilman conflict resolution model sees that collaboration as a positive mode and can be distinguished from competing, compromising, accommodating and avoiding. Meads 2005) (See Appendix 4)Teams however are vulnerable to disintegration where members revert to their more established roles within their professional boundaries.

(Leathard 2000) A number of major reasons have been consistently identified as inhibiting inter-professional working and these can be seen to fall into four main categories, Ideological differences, unequal power relations, communication and role overlap, (Caldwell &Atwal 2003) however important features in successful integrated care pathways e. . : They are agreed by all members of the multi-disciplinary team that are involved in the episode of care, The focus is on the client rather than any one professional group, and the care contained within that pathway is based on the very best evidence available (Harris in Spouse 2008 pg 405) should remove any potential barriers that may arise.Many clinical areas used integrated care pathways each is based on the evidence and best practice and describes the plan of care that should be given to the patient with a specific condition, it may have been useful to have one of these in place for all of those who receive care in this unit, as the care could have been detailed coupled with any knowledge of Alex’s behavioural problems identified during any work the staff had done previously with outside organisations in developing Alex’s profile of strengths and weaknesses enabled them to put an alternative action in that suited Alex involving him in the decision making process at the outset. ICP’s are followed by all members of the multi-disciplinary team, it also enhances a greater understanding within the multi-disciplinary team, enabling them to deliver an agreed plan of care working toward the principle that teamwork is a collaborative effort of all of those concerned with the care of a client.

Clients do not belong to any one professional they are the responsibility of all those that take care of them. Kennedy 2001) Services exist to support people with learning difficulties yet all too often organisational concerns have come to dominate, the kinds of services on offer and they way that they are delivered. This meets less the needs and wishes of those who need this service and more to the needs of the organisation that provides them. (Simons 1998) The operating framework for the NHS describes each year how priorities should be addressed and measured, the new performance framework (2007) builds on the local government white paper “strong and prosperous communities” which promised greater freedom for local government to set their own priorities.A specific target relating to learning difficulties was included in the 2008/2009 as a target with priority for local action, however when “Vital Signs” was published its classification had been changed and no longer identified as a national policy enabled primary care trusts to ignore it if they so wished. (Sir Jonathan Michael 2008) Recent media coverage has shown there is still a great deal of work to be done when dealing with those with learning difficulties. A recent ombudsman enquiry found that patients with learning difficulties were treated less favourably than others resulting in prolonged suffering and inappropriate care.

After an investigation into the deaths of those with learning disabilities in NHS care. It went on to say that care as at best patchy, basic policy and guidance was not observed, needs were not met and service were uncoordinated (Carrel 2009) and the joint committee on Human Rights concluded regrettably in their report that it was still necessary to emphasise that those with learning disabilities have the same rights as everyone else, and that the fundamental rights to Humanity, Dignity,Equality,Respect and Autonomy were still not being met. (Sir Jonathon Michael 2008)In conclusion, because the professional is in a more advantageous position than Alex it is the professionals’ responsibility to honour the special obligations that emerge from the inequality and in return Alex must trust the professional. However the emphasis is on the professionals’ worthiness of the Alex’s trust. Alex needed to be fully involved in the decision making process, but as he was in a less informed position, he was reliant on the professional to analyse the situation and suggest options for its resolutions. Althea&Ewens 1998) The change in focus from procedure led to person centred perspectives would encourage the development of good communication between Alex and the professionals, this would enable all professionals to work together to ensure that there is direct work with the Alex and that all parties would be able to support him. (Koubal 2009. )To do this it is helpful to examine communication theory and the goal is to examine the links between cognition and behaviour.

Cognition is generally accepted to mean the process of thought, As with all cognitively impaired clients the process of thought would be different to that of the professional. Anderson 1996) Through effective and clear communication we gain vital information about our clients, needs, thoughts and feelings enabling us to alleviate fears, minimize discomfort and assist with individual adjustment, As Stuart suggested communication can either facilitate the development of a therapeutic relationship or create barriers. (Stuart & Sundeen 1995)For any professional to work with those with learning disabilities sensitive human interaction is an essential core skill, the need for great patience and highly developed communication skills is a must from all members of the multi-disciplinary team within the professional-client relationship.In the setting ground rules, at the beginning with Alex and introducing and Integrated Care Pathway could have resulted in the establishment of a relationship, that was respectful of both parties.

Autonomy places the client at the centre of the decision making process, the conduct of the relationship should be guided within the ethical framework for practice, ensuring that professionals fulfil their obligations in which they are engaged whilst at the same time the client remains fully involved in the management of the relationship, it is important that there is a consultation and feedback with people with learning disabilities who may need support to put their point of view. (HMSO 1995)



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