Person-Centered Care and Interprofessional Practice - Essay Example

Person-Centered Care and Interprofessional Practice An Outline of the Incident I was working in a mental health facility that dealt with old people who mainly suffer from dementia. The incident involved an old lady who was being brought within the system with dementia but who was claiming that she "wanted to go home" throughout the whole process. From a cursory look it seemed as though the lady was suffering from dementia and was unaware both of where she was and what was occurring. She was clear about her wish to "go home", but about little else. The situation worsened into one in which the lady was trying to get up from the seat and walk out of the facility. Initially, some of the male nurses that were in the are essentially blocked her path out of the intake area by standing around her chair. Eventually this was no longer sufficient and they needed to hold her in the chair. This was done in a gentle manner, only utilizing as much force as possible to restrain her. The old lady started to struggle a lot and it seemed as though the amount of force needed to keep her in her seat would perhaps end up hurting her. The doctor-on-call then arrived at the scene. After a few seconds being told about what had happened so far and summing up the situation with his own eyes, he ordered a strong sedative for the old lady. She was given this within seconds and subsequently appeared to fall into only a semi-conscious state. The rest of her intake into the facility occurred smoothly and she was taken inside the main are by wheel-chair as she seemed to have fallen asleep. 2. Person-Centered Care: The Roles and Responsibilities of Professional Practitioners The client-practitioner relationship is one of the most essential elements of any healthcare delivery system, but it has often been overlooked in favor of the apparently more cold methodology of the scientific method. This relationship recognizes the fact that each client will have specific feelings, emotions and psychological features that affect their condition and also their relationship with the practitioner. In the same way, the practitioner is also a unique human being with unique attributes. It is the unique relationship between these individuals that client-practitioner research attempts to explore, as well as defining general trends and characteristics that may be seen within all such relationships. Within the context of the described incident, person-centered care can be defined as seeing to the physical needs of the patient as much as possible while also considering the emotional effects of her current situation. Thus the patient was being admitted to the hospital for her own physical well-bring, but did not understand this fact. While her emotions and feelings regarding the admission would normally be taken into account, they could not be to the same degree as they would be with a person who understood what was occurring. The client-practitioner relationship is an essential element of the healing process. It may range from ethical standards that a practitioner needs to follow when dealing with a patient to the effect that it will have on possible treatment and outcomes. The study of the relationship may be basically divided into two basic types: a positive approach that suggests how the relationship may help treatment outcomes, and an approach that concentrates upon negative possibilities such as emotional attachments, sexual relationships and various ethical concerns that arise within the client-practitioner relationship. One method of both establishing and maintaining a positive client-practitioner relationship is to establish and maintain trust at the first meeting. Thus all patients should be treated with equal respect and concern, whatever the personal bias of the practitioner. A practitioner must try to treat a highly-educated, articulate and friendly patient in the same manner as the dim-witted and abusive client. A way of maintaining the relationship is to be sure that all aspects of the patient's care are kept confidential and that they are shown to be confidential to the client. Here the issue of those factors which help or hinder person-centered care become clear as the issue of "trust" with a dementia patient exhibiting symptoms in which they have little idea where they are or what is happening to them takes on an added complexity. The patient is not capable of "trusting" the practitioner because they may not, as appeared to be the case with the old person suffering from dementia, know that a practitioner is actually treating them. In this case, the issue of trust passes on to the family, friends or other concerned parties who are responsible for the patient. A kind of proxy trust exists in which the practitioner has to gain the trust of people who feel that it is their responsibility to make sure that the patient receives the correct treatment. The fact that it is not the patient who needs to trust does not lessen the importance of trust, indeed, in many ways it almost magnifies it. Those who have others to be responsible for often feel an even greater need to control and understand the treatment regimen because they have, in one sense, the life of a loved one in their hands. This situation is intensified when, as if often the case, it is the adult child of the patient who is now responsible for making their medical decisions. The apparent reversal from the traditional parent-child relationship, in which the child becomes the adults, and the parent is now the helpless child, often causes great anxiety and stress within the adult child. A practitioner needs to recognize this fact and deal with the responsible party accordingly. The Interprofessional collaboration that is needed for person-centered care to effectively occur was illustrated by the various personnel involved with the process of admitting the patient. Thus the intake nurse was taking the details of the patient initially, but when she started to become upset other nurses became involved. At first these were just used to passively block possible exits for the patient, but then took a more active role when it was clear that this would not suffice. They acted on their initiative at this point because it was clear that they had worked with the intake nurse before and all understood the professional duties of the others involved. The doctor who eventually ordered sedation for the patient initially asked the intake nurse what was occurring - thus showing a degree of professional courtesy, even though a single glance must have enabled him to correctly sum up the situation. One of the other nurses got the required medication and injected it into the patient. Thus a seamless Interprofessional collaboration occurred, all of which was aimed at the best interests of the patient. Hindrances to such collaboration might have occurred had the staff involved not known each other's style and habits of work. Also, if succinct and informative communication does not occur then confusion may develop. This would be particularly important within a time-sensitive situation such as the one involving the dementia patient: decisive and correct action was needed in order to stop her hurting herself and/or others. Had the intake nurse, other nurses and the doctor not worked seamlessly and cooperatively with one another the situation might have got out of hand. The practitioner must admit to him/herself that part of the treatment of a client involves subjective as well as objective elements. Thus objective standards suggest that there is a strict causal relationship between cause, condition, and treatment of illness. The actual individual involved has little influence beyond the circumstances of their own disease. Subjectivity admits that diseases may be unique to individuals and must be treated as much: they may vary more than they coalesce from patient to patient. This treatment of the client as an individual human being is essential to creating a positive relationship. They should be an individual rather than a number. It is of course rather difficult to treat a patient suffering from dementia as an individual, because they often seem to lose that sense of individuality that is the hallmark of healthy patients. The practitioner, rushed, stressed and faced with numerous cases that seem to present exactly the same symptoms, may be tempted into classifying the patients into convenient definitions and no longer treat them as an individual. Thus the old lady in this case might be classified as "acutely confused and belligerent", summoning a standard response. The uniqueness and individuality of her case, and the basic human right to be treated with respect, may become lost within her apparently generic and easily identified symptoms. If the patient seems to have descended into a condition in which they are no longer an individual but rather an amalgam of symptoms that more or less coincide with text-book definitions, the practitioner must treat the responsible party as an individual. In this way the practitioner may actually treat the patient as an individual as the unique circumstances surrounding the person who now makes their medical decisions - whether it be spouse, adult child or other responsible party - bring an element of uniqueness to what may be otherwise a generic case. The literature on client-practitioner is as varied as relationship is complex. One particular element studies the client's right to self-determination as the central feature of any such relationship. Mayer (2005) suggests that "boundary issues" may be a key threat to this self-determination, as the practitioner may know more than the client and may thus feel better equipped to decide on the appropriate course of action, but must always leave the final decision to the client. This was obviously the situation with the case of the old lady, who was not aware of her surroundings, let alone of the benefits that might accrue for her by her entrance into the facility. In this case, the "right to self-determination" is a difficult concept as, while legally an adult and thus enjoying all the rights that all adults possess, the lady was in fact unable to make her own decisions. At some point those suffering from dementia are no longer legally responsible for themselves and must, in some senses at least, be dealt with as if they were an infant incapable of rational thought. In other words, there is no dilemma posed by medical decisions being made on behalf of a three year-old, even though they may well show more awareness of their surroundings and what is occurring to them than the senior citizen suffering from dementia. The difference between an demented old person and an toddler is that the former is on a downward path from a position of self-determination, whereas the latter is merely on a fairly predictable path towards adulthood. The problem for the practitioner is that persons with dementia may exhibit periods of apparent "normality" in which self-determination seems not only desirable, but a right. These periods tend to become longer as dementia advances (Mendez, 2003) At some point the practitioner (in consultation with the person responsible for the patient's care) must decide whether the patient is now not at all capable of making their own decisions. They must decide, essentially, when the patient is no longer to be regarded as a responsible adult, even within the apparently lucid periods. The practitioner must be aware that this is a decision of extreme emotional difficulty for the person, especially if they are an adult child of the patient. This moment represents a break in the normal parent-child relationship that is often maintained well into the apparent total independence of adulthood for the "child". In other words, the mental-health practitioner needs to consider the effect of the decisions being made on the adult child as well as the patient, even though ultimately it is of course the well-bring of the patient that is paramount and trumps all other concerns. Another large segment of the literature deals with cultural differences that may occur and the need to be aware of them in building a strong client-practitioner relationship. Murdock (2005) suggests that boundaries and taboos may be accidentally broken by people from two contrasting cultures meeting. Nonverbal communication is an essential element of such problems, as Klopf suggests, "an innocent gesture made in response to a simple question may be an unwitting insult, or worse." Other factors such as visual communication (clothes etc.), rhetorical style and the communication matrix (how the various communication components fit together in a specific culture) will all have a profound effect on the client-practitioner relationship. With a patient suffering from dementia an apparently innocent verbal comment or physical gesture may be taken completely out of context and be a source of great stress to the person. The practitioner must closely watch for such triggers, however apparently innocent or rational they appear to be to the staff, and avoid them wherever possible. On the more positive side, a great body of work exists that explores the manner in which a positive client-practitioner relationship can produce great benefits for the prognosis of a condition or disease exists. As there is no "cure" for dementia, it is the ongoing treatment of this chronic decision that is most important to the practitioner. Betty Neuman is one of the major proponents of an overall holistic approach to patient care. The basic concept of the Neuman model is that each person is made up of five different layers, or concentric circles (Neuman, 1972) : 1. Physiological - physiohemical structure and function of the body. 2. Psychological - mental processes and emotions. 3. Sociocultural - relationships, social/cultural expectations and activities. 4. Spiritual - the influence of spiritual beliefs. 5. Developmental - those aspects concerned with lifetime change/development. These layers need to be considered simultaneously and comprehensively. When a patient first presents himself with a disease, the basic structure, or "central core" (Neuman, 1972) needs to be considered. This core is made up of basic survival factors such as genetic features, the innate strengths and weaknesses of particular boy systems and also the general functioning of the body system. This system includes "cognitive ability, physical strength and value systems." Neuman also identifies the "flexible line of defense" and the "normal line of defense" (Reed, 1993). The first is a series of system qualities that enables the body to defend against periodic attacks on its stability (the immune system is an example), whereas the normal line of defense are stable structures that keep a protective distance between the body and the outside environment. The skin is a prime example of this kind of defense. The flexible line of defense is referred to as "accordion-like" by Neuman (1972) in her initial description. Apart from the physical origins of disease that are taken into account by the Neuman model (taken from traditional medicine), she also identifies "stressors" that can potentially affect the stability of the system. These include intrapersonal stressors, such as emotions that occur inside people, interpersonal stressors that occur in their relationships with others and extrapersonal stressors that occur within work/finance problems. All of these may be present and are influenced by the client-practitioner relationship; if acknowledged and worked with they can actually provide benefits for the patient. With a case of dementia it becomes obvious that the biological (physical) causes of the disease are very important, and yet also the "extrapersonal stressors" are contributory to the actual symptoms that a patient presents at any one time. Thus theory leads to the idea that prevention is the most important nursing intervention that can be performed, This prevention concentrates on limiting both the number and the scope of stressors that an individual is subject to. In the case of a patient suffering from dementia, the practitioner should discover which stressors tend to bring on the worst symptoms and avoid them, while trying to concentrate on those that produce a safer and more relaxed environment for the individual involved. Newman's model to nursing is proactive rather than reactive, and it is, with some adaptation, very applicable to the mental health situation. Dementia cannot, at the present time, be prevented through proactive care, but the worst of its symptoms can be alleviated through the proactive process outlined above. At times, however, a reactive response from a practitioner is necessary. Thus if the person in the incident described had shown passive behavior (another symptom of dementia) then no intervention would have been needed. The reactive element only appeared because the patient was not passive, but rather actively resisting admission to the facility. The only time a patient should be "forced" against "their will" (if will is a sensible concept within severe dementia) to undergo treatment is when they are clearly unable to decide rationally whether to accept treatment or not. Neuman's model has been a powerful influence in the development of medical programs (at all levels, from certificates in nursing to full-scale MD) in British and American medical programs that take into account the whole human being rather than just the symptoms that are being presented at a particular time. There are problems with Neuman's theory that show the importance of considering each individual patient as just that, a unique person with unique needs and desires: " . . . the question must be asked as to how accurate the model is in representing human beings in their interaction with the environment. While it is useful to think of people as layered and made up of five principles, it is always not easy to predict or describe their interplay. Moreover, since each layer is composed of all the person variables, it is not always clear as to what layer is being assessed in any operational variable. (Patheyman, n.d.) The various types of research that have been undertaken into client-practitioner relationships all suggest that they are vital to the overall treatment process; from diagnosis to cure. The difficulty of including complex (and often inexact) psychological factors within what has become an often rigidly rationalistic applied science: - medicine - has often caused the relationship to be pushed to the side in studies. However, increased realization of the importance of such emotional factors is causing practitioners to rethink their attitudes. The "emotional factors' not only need to be considered with dementia patients but are, as most of the symptoms of the condition are mental rather than physical in nature, central to the whole treatment process. To conclude, the client-practitioner relationship is one that requires a great deal of experience to perfect. While the symptoms and cures of various diseases and conditions can be fairly easily mastered, the relationship with the patient requires a degree of sheer time (and number of patients) to develop. It seems clear that the practitioner needs to treat all clients with the same degree of decency and respect, and yet at the same time to adjust their relationship to the individual characteristics/needs of each client. These might seem contradictory impulses at first glance: the need for uniformity and yet also the need for adaptability. However, respect for the patient does not presuppose exactly similar treatment. The young, highly-educated individual that understand a lot about medical science can be talked to in a different manner than a less-educated older person who may need conditions explained in simpler terms. Within the mental health field, a whole range of other factors and standards become involved, as the case of the old lady suffering from dementia illustrates. Respect involves adapting the relationship to the needs of the individual before the practitioner rather than some cookie-cutter approach that will appear to resemble the "patient as number" syndrome that medicine has increasingly fallen into. Scholarship may inform the creation of a successful client-practitioner relationship, but it is intuition that actually creates it. Works Cited Klopf, Donald. Intercultural Encounters: Fundamentals of Intercultural Communication. Morton, Englewood: 1998. (p.218) LaRay, Barna. "Stumbling Blocks in Intercultural Communication". in Samovar, Larry et al. (eds) Intercultural Communication: A Reader. Wadsworth, Belmont: 1988. Mayer, Lynn. "Professional Boundaries in Dual Relationships: A Social Work Dilemma". The Journal of Social Work Values and Ethics. September, 2005. Mendez, Mario. Dementia: A Clinical Approach. Butterworth, London: 2003. Murdock, George. "The Common Denominator of Cultures" in Linton, Ralph (ed.) The Science of Man in the World of Crisis. Columbia UP, New York: 1995 Neuman, Betty. "A Model for Teaching Total Person Approach to Patient Problems." Nursing Research, 21, pp. 264-269. 1972. www.patheyman.com/essays/neuman Read More